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BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email
on February 9, 2021 by guest. P
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Are healthy children attended by Family Physicians or
Pediatricians?
Determinants of an important decision.
Journal: BMJ Open
Manuscript ID bmjopen-2017-015902
Article Type: Research
Date Submitted by the Author: 10-Jan-2017
Complete List of Authors: Rebelo, Susana; Family Health Unit S. Miguel-o-Anjo Rua, Sofia; Family Health Unit Ribeirão, Leça, Joana Couto, Ana; Family Health Unit S. Miguel-o-Anjo Teixeira, Rute; Family Health Unit S. Miguel-o-Anjo Machado, João; Western Oporto Public Health Uni
Keywords: Pediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice
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Are healthy children attended by Family Physicians or Pediatricians?
Determinants of an important decision. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João
Firmino-Machado6
Sofia Velho Rua and Joana d’Orey Leça equally contributed to this article.
1 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Susana Rebelo Family Medicine Res-
ident.
2 Family Health Unit Ribeirão, Northern Regional Health Administration, Rua da Extensão de
Saúde, 4760-715 Ribeirão, Portugal, Sofia Velho Rua Family Medicine Resident.
3 Family Health Unit Terras do Ave, Northern Regional Health Administration, Rua do
Pavilhão, 4765-628 Delães, Portugal, Joana d’Orey Leça Family Medicine Resident.
4 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine Resident.
5 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Rute Teixeira Family Physician
Assistent.
6 Western Oporto Public Health Unit, Northern Regional Health Administration, Rua de Vila
Nova 503, 4100 Porto, Portugal, João Firmino Machado Public Health Resident.
Corresponding to: S Rebelo [email protected]
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Abstract
OBJECTIVES: To determine if children attend the Family Physician (FP) or the FP/Pediatrician
for their surveillance consultations, as well as the variables associated with parents’ choice
between the two physicians.
DESIGN: Cross sectional study.
SETTING: Public, semi-private and private kindergartens in the city of Vila Nova de Famalicão
(Portugal).
PARTICIPANTS: Parents of children enrolled in the selected kindergartens, aged 6 years old or
less, without chronic diseases.
MAIN OUTCOME MEASURES: Proportion of children attending the FP or FP/Pediatrician for
their surveillance consultations. Association between the chosen Physician and
sociodemographic and household variables (parents´ age, educational level, professional
situation and marital status; household net income; number of children; child´s age; presence of
private health insurance). Assess the parents' perception of clinical knowledge and
accessibility, regarding the Family Physician and the Pediatrician.
RESULTS: A total of 697 children were included in the analysis: 30.6% attended only the FP
and 69.4% attended both the FP and the Pediatrician. Using a multivariate binary logistic
regression, the mother´s age (OR=1.06, 95% CI 1.02-1.11), higher educational level (OR =
2.52, 95% CI 1.46-4.34), household net income higher than 2000 euros (OR= 12.14, 95% CI
3.12-42.27), private health insurance (OR= 4.18, 95% CI 2.55-6.84), number of children
(OR=0.56, 95% CI 0.42 – 0.75) and the child’s age (OR= 0.98, 95% CI 0.97-0.99) were
significantly associated with attending both the FP and the Pediatrician. Parents of children who
attended only FP rated the FP with a higher accessibility and knowledge mean score than those
who consulted both physicians (2.90 versus 2.38, p<0.001, and 4.22 versus 3.70, p<0.001).
CONCLUSIONS: Our data shows that 70% of our sample simultaneously attended a FP and a
Pediatrician. Family Physicians are equally qualified to provide medical care to healthy children
but this information is not properly transmitted to the general population.
Keywords: Pediatric Assistant, Family Physician, Infant, Preschool Child, Primary
Health Care, Family Practice.
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Strengths and limitations of this study
- This study carefully assessed the determinants on the parents’ choice between the FP or
the FP/Pediatrician for their surveillance consultations of their children.
- Family Physicians still play an important role on children’s follow-up, even though ap-
proximately 70% of our sample simultaneously attended a Pediatrician.
- Mother´s age and her educational level, household net income, private health insurance,
number of children and the child’s age are associated with attending both the Family
Physician and the Pediatrician.
- We could only determine the variables associated with attending the FP or the Pediatri-
cian, but not the causes of this decision.
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Introduction: According to the Robert Graham Center, in the United States, the ratio of children’s health care
provided by Family Physicians (FPs) decreased by about 33% between 1992 and 2002, from
one in four children to one in six.1,2 At the same time, there was an increase in the number of
visits provided by Pediatricians. FPs provide care to approximately 20% of the children between
birth and 5 years of age and increases to nearly 50% for adolescents, compared with 78% and
44%, respectively, in the case of the Pediatricians.1
FPs located in rural and underserved urban areas are more likely to provide care to children than
those in areas with higher pediatrician density.2,3 Children without health insurance or with
public health insurance are also more likely to be attended by FPs.1 Regarding the physician’s
characteristics, younger age and female sex are positively associated with medical care being
provided by FPs.3
In Portugal, like in other European countries such as the United Kingdom, the health care
system operate by the National Health Service (NHS), which is characterized by universal
coverage, tax financing and public provision4.
From 1992 to 2015, the number of Pediatricians and FPs more than doubled 5 and the birth rate
declined from 11.5 to 8.3 live births/1000 persons.6 The National Program for Child and
Juvenile Health establishes 18 surveillance consultations at specific ages, 13 of them on the first
6 years of life.7 These consultations are intended to be done in the Primary Health Care
network, were the children received their vaccination as part of the Portuguese National
Vaccination Plan, which is free and available for all the children.8 Even though in Portugal
there are no official numbers, it is clear that the number of children who are simultaneously
attended by Pediatricians in private care is rising.
Therefore, the main objectives of our study were to determine if children attend the FP or the
FP/Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the two physicians.
This takes particular importance since it was the first study to be done on this matter, as far as
we know.
METHODS:
Study design This was a cross sectional study. In order to determine the factors associated with parents’
choices in the medical care of their children, a questionnaire was designed by the investigators.
This consisted of two parts: the first comprised direct questions about the sociodemographic
characteristics related to parents, children and the household. The second part consisted of
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statements about accessibility and knowledge, regarding the Family Physician and the Pediatri-
cian, to be rated according to a Likert scale. This scale includes five ordered response levels
varying between 1 and 5, measuring either negative, neutral or positive response to a statement.
There were three questions about the clinical knowledge regarding each physician and four
about the accessibility. The latter included questions about appointment scheduling (urgent,
surveillance and after working hours consultations), and the possibility to establish telephone
contact with the physicians.
Content validity was tested with eligible patients and minor modifications were implemented.
Data obtained by this process was not included in data analysis.
Ethical approval was obtained from the City Council of Vila Nova de Famalicão regarding the
public institutions and by the directors of the private and semi-private kindergartens, as required
by national legislation.
Setting and Study size
The study population comprised all children up to and including those with 6 years of age,
enrolled in public, semi-private and private kindergartens in the city of Vila Nova de Famalicão,
a county in the north of Portugal.
According to national statistics, in September of 2015, there were 4989 children enrolled in the
kindergartens in the municipality of Vila Nova de Famalicão.9-10 We determined a minimum
sample size of 536 valid questionnaires using OpenEpi, with a prevalence of 50%, a confidence
interval (CI) of 95% and a design effect of 1.5. We considered that the number of delivered
questionnaires should be three times greater in order to deal with non-delivered questionnaires
and the exclusion criteria, that could not be anticipated. At the time, this county had 89
kindergartens, 47 were public, 29 semi-private and 13 were private.11 We used a random sample
that was stratified by school type – public, semi-private, private. Strata weights were calculated
using the number of students in each specific stratum and the total number of students in all
schools. In each strata, schools were considered as sampling units and were randomly selected
with selection probabilities proportional to the number of students. In each stratum, school
selection process ended when the total number of children was superior to the determined
sample size, for each school type. For each school, all the parents were invited to participate.
Participants
Parents of children from the selected kindergartens were personally invited to participate and
the purpose of the study was explained to them by the teachers, who were previously trained by
the investigators. The parents who accepted to participate signed an informed consent and
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received a questionnaire, delivered by the preschool teachers between April and May of 2016.
Surveys were preferably answered at home by both parents. It was guaranteed the anonymity
and confidentiality of the data of all the participants, as they placed the unidentified
questionnaires in a sealed box. They were then collected by the investigators in June 2016.
We excluded the following children: those with chronic diseases followed by Pediatricians in
public hospitals; those up to 2 years old who had a Pediatrician but did not attend their services
in the last year, and those older than 2 years old that did not have a consultation in the last two
years. We also excluded children who did not have a FP and those who had a FP but did not
have adequate surveillance. Based on the National Program for Child and Juvenile Health6, we
defined inadequate surveillance as attending less than 80% of the consultations for children up
to 2 years old, and not attending the FP in the last 2 years for older children. Surveys that were
incomplete (under 80% of answered questions) were not considered for data analysis.
Variables
We included 13 sociodemographic and household variables in the analyses: parents’ age,
education level, professional situation and marital status; household size and net income;
number of children; child´s age and health insurance situation. Additionally, two more variables
were included, accessibility and clinical knowledge, related to the FP or Pediatrician.
Statistical methods
For statistical analysis, responders were divided in two groups: children that attended only the
Family Physician (FP group) and children that attended both the Family Physician and the
Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages, and continuous variables as
means and standard deviations. Shapiro-Wilk test was used to test for Normality.
Differences between FP and FP/Pediatrician groups’ characteristics were tested using qui-
square test or independent sample T-test, as appropriate. Multivariate binary logistic regression
model was used to determine the variables associated with FP or FP/Pediatrician group. This
model included as independent variables only those identified in univariate analysis, with p-
values <0.1.
Perceptions of accessibility and knowledge were compared between FP and FP/Pediatrician
groups using independent T-tests. Additionally, accessibility and knowledge about the Family
Physician and Pediatrician were compared using a paired sample T-test, only for children who
belonged to the FP/Pediatrician group.
Statistical analysis was performed with SPSS v23.0 and p<0.05 was defined as statistically
significant.
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RESULTS
A total of 697 questionnaires were considered for the analysis (Fig 1), 213 (30.6%) from the FP
group and 484 (69.4%) from the FP/Pediatrician group. The global missing data was 1,2% and
for each individual variable inferior to 3%.
Table 1 summarizes the sociodemographic and household characteristics of the participants
involved in the study. We found significant differences between the two groups for all the vari-
ables, except for the father´s age. Higher education was more frequent in the FP/Pediatrician
group (42.3% versus 10.4% for the mother, p<0.001, and 24.9 % versus 5.4 % for the father,
p<0.001). Active professional status was more frequent in FP/Pediatrician group compared to
the FP group (90% versus 78.3% for the mother, p<0.001, and 94.8% versus 86.8% for the fa-
Fig 1| Flowchart showing the sample selection.
1539 delivered questionnaires
1138 questionnaires collected
441 excluded: - 206 (18,1%) due to chronic illness/hospital attendance - 190 (16,7%) due to incomplete answering - 27 (2,4%) did not have adequate surveillance - 18 (1,6%) did not have a FP
697 questionnaires considered for data analysis
Public institutions nschools = 23 nchildren = 735
Semi- private institutions nschools = 11 nchildren = 596
Private institutions nschools = 5 nchildren = 208
Public institutions Nschools = 47 Nchildren = 2306
Semi- private institutions Nschools = 29 Nchildren = 1951
Private institutions Nschools = 13 Nchildren = 732
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ther, p<0.001). Higher incomes were also more frequent in the Pediatrician/FP group, with
71.3% having a monthly net income of 1000 euros (847£; 2245$) or more, compared with only
36.3% in the FP group. Additionally, 45.1% of the children in the PF/Pediatrician group and
only 13.3% in the FP group had a private health insurance (p<0.001).
Table 1| Sociodemographic and household characteristics of the participants (n=697)
*500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$;
†Number of people living in the same house. ‡Total number of children of both parents. SD: standard deviation; FP: Family Physician.
Total
n= 697
FP group
n= 213
FP/Pediatrici
an group
n= 484
p-
value
Mother’s age (years)
Mean ± SD
34.43 ± 4.96
33.61 ± 5.71
34.81 ± 4.49
0.005
Mother’s education
Without higher education
With higher education
468 (67.4%)
226 (32.6%)
190 (89.6%)
22 (10.4%)
278 (57.7%)
204 (42.3%)
<0.001
Mother’s professional situa-
tion
Not active
Active
94 (13.5%) 600 (86.5%)
46 (21.7%)
166 (78.3%)
48(10.0%)
434 (90.0%)
<0.001
Mother’s marital status
Single
Divorced/separated
Married/cohabiting couples
56 (8.1%)
31 (4.5%)
608 (87.5%)
27 (12.7%) 16 (7.5%)
170 (79.8%)
29 (6.0%)
15 (3.1%)
438 (90.9%)
<0.001
Father’s age (years)
Mean ± SD
36.72 ± 5.30
36.36 ± 6.01
36.91 ± 4.96
0.331
Father’s education
Without higher education
With higher education
556 (80.9%) 131 (19.1%)
194 (94.6%)
11 (5.4%)
362 (75.1%)
120 (24.9%)
<0.001
Father’s professional situation
Not active
Active
52 (7.6%) 634 (92.4%)
27 (13.2%) 177 (86.8%)
25 (5.2%) 457 (94.8%)
0.002
Father’s marital status
Single
Divorced/separated
Married/ cohabiting couples
51 (7.4%) 35 (5.1%) 602 (87.5%)
23 (11.2%) 15 (7.3%) 167 (81.5%)
28 (5.8%) 20 (4.1%) 435 (90.1%)
<0.001
Household net income*
≤500€
501 to 999€ 1000 to 1999€
≥2000€
39 (5.8%) 225 (33.5%) 318 (47.4%) 89 (13.3%)
24 (11.8%) 106 (52.0%) 70 (34.3%) 4 (2.0%)
15 (3.2%) 119 (25.5%) 248 (53.1%) 85 (18.2%)
<0.001
Private health insurance
No
Yes
449 (64.6%) 246 (35.4%)
184 (86.8%) 28 (13.2%)
265 (54.9%) 218 (45.1%)
<0.001
Household size†
Mean ± SD
3.63 ± 0.78
3.79 ± 0.82
3.57 ± 0.75
<0.001
Number of children‡
Mean ± SD
1.66 ± 0.72
1.84 ± 0.79
1.58 ± 0.672
<0.001
Child’s age (months)
Mean ± SD
48.02 ± 19.65
52.08± 18.31
46.23 ± 19.98
<0.001
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We adjusted a binary logistic regression considering as dependent variable attending a FP or
attending FP/Pediatrician, and as independent variables all the ones presented on Table 1 except
father´s age. Mother´s age and educational level, household net income, private health
insurance, number of children and children´s age remained significantly associated with
attending both physicians. With an odds ratio (OR) of 1.06 for the mother´s age (95% CI 1.02-
1.11), 2.52 for the mother's educational level (95% CI 1.46-4.34), 2.78 (95% CI 1.15-6.75) for
household net income between 1000 and 1999 euros (847-1692£; 1123-2245$), and 12.14 (95%
CI 3.12-42.27) for those higher than 2000 euros (1693£; 2246$), 4.18 for having a private
health insurance (95% CI 2.55-6.84), 0.56 for the number of children (95% CI 0.42-0.75) and
0.98 for the child´s age in months (95% CI 0.97-0.99).
Table 2| Binary logistic regression for determination of variables associated with FP and FP/Pediatrician group.
Independent variables
OR
95% CI for OR
p-value
Mother´s age (years) 1.06 1.02-1.11 0.05
Mother’s education
Without higher education
With higher education
1
2.52
—
1.46 – 4.34
— 0.001
Household net income*
≤500€
501 to 999€ 1000 to 1999€
≥2000€
1 1.36 2.78 12.14
—
0.57 – 3.26
1.15 – 6.75
3.12 – 42.27
—
0.496 0.024
<0.001
Private health insurance
No
Yes
1
4.18
—
2.55 – 6.84
—
<0.001
Number of children‡ 0.56 0.42 – 0.75 <0.001
Child’s age (months) 0.98 0.97 – 0.99 0.002
Hosmer and Lemeshow test 5.49 (8), p=0.704
R2 (Nagelkerke)
35%
ROC Curve AUROC = 0.81 (0.78 – 0.85), p<0.001 *500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; ‡Total number of children of both parents. ROC: Receiver Operating Characteristic. AUROC: Area Under the ROC Curve; OR: Odds Ratio. CI: Confidence interval.
Regarding the parents’ perception about accessibility and clinical knowledge of the physicians,
we found statistical differences between the two groups (Table 3). The FP group rated the FP with
a higher accessibility and knowledge mean score comparing with FP/Pediatrician group (2.90
versus 2.38, p<0.001, and 4.22 versus 3.70, p<0.001). In the FP/Pediatrician group, the mean
score of accessibility and knowledge was significantly higher for the Pediatrician comparing
with the FP (4.29 versus 2.38, p<0.001, and 4.11 versus 3.70, p<0.001).
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Table 3| Parents’ perception on accessibility and knowledge of the Family Physician and the Pediatrician.
Items about Knowledge related to
the: Items about Accessibility related to
the:
Family Physician Pediatrician Family Physician Pediatrician
Participants with Family Physician
4.22 ± 0.75* ------ (a)
2.90 ± 1.09* ------
(a)
Participants with Family Physician and Pediatrician
3.70 ± 0.88*
4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.78*
*mean ± standard deviation; (a) – did not have a Pediatrician
Discussion
In our study, only about 30% of the children attended exclusively the FP for surveillance con-
sultations, and 70% of the sample attended both the FP and the Pediatrician.
We found that the mother´s age and her educational level, household net income, private health
insurance, number of children and the child’s age were associated with attending both the FP
and the Pediatrician. Variables with higher impact in the parents’ choice were household net
income higher than 2000 euros (OR =12.14, 95% CI 3.12-42.27), followed by having a private
health insurance (OR= 4.18, 95% CI 2.55-6.84). Both mother´s age and her educational level
were significantly associated with attending both physicians. However, father´s age and his
educational level were not associated with the parents’ choice. This could be explained by social
and cultural influences in Portugal, where the mother is still recognized as the center of nurture
and care in the family life. Additionally, the number of children and the child´s age were also
associated with the parents’ choice. As the number of children increases within the household
and children grow older, there is an increasing odd of being followed only by the FP for surveil-
lance consultations. We think this may be explained by a higher experience and knowledge of
the parents about the child’s health. Furthermore, economic reasons may influence this choice
as the number of children grows. Our results are supported by the Robert Graham Center study1
findings: the proportion of children attending the Pediatrician decreases as the child grows older
and children with private health insurance are more likely to attend the Pediatrician. Regarding
parents’ perception of accessibility and clinical knowledge of the Family Physician and the Pe-
p<0.001 p<0.001 p<0.001 p<0.001
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diatrician, we found statistical differences between the two groups. Parents who attended both
physicians rated the FP with lower accessibility and knowledge than those who consulted only
the FP.
Strengths and limitations
To our knowledge, there are no previous studies available regarding the factors associated with
parents’ choice in the medical care of their children, so this is the first one addressing this im-
portant subject. Other strengths of our study are an adequate sampling, taking into consideration
the three existing school types: public, semi-private and private.
The main limitation was that we could only determine the variables associated with attending
the FP or the Pediatrician, but not the causes of this decision because causality can not be evalu-
ated due to the study design.
Conclusions and implications for future research and practice
Our data shows that Family Physicians still play an important role on children’s follow-up, even
though approximately 70% of our sample simultaneously attended a Pediatrician.
We identified variables associated with the parents’ choice in the medical care of their children,
with household net income and private health insurance being the most relevant ones.
Unlike Pediatricians, the role of FPs is still unclear to most parents since they rated the FP with
a lower clinical knowledge mean than the Pediatrician. However Family Physicians and Pedia-
tricians are equally qualified to provide medical care to children without chronic diseases, with
the advantage that costs associated with the same surveillance consultations are lower when
carried out in Primary Health Care.12-15 Moreover, these facts should be advertised and included
in health care promotion and education that is provided to parents and general population.
Additional investigation is relevant to understand if children’s medical care provided simulta-
neously by a Pediatrician and a FP is associated with health benefits and higher public health
costs when compared to medical care provided exclusively by the FP
Footnotes
We thank the City Council of Vila Nova de Famalicão, the institutions that participated in the
study and all the parents who kindly completed the questionnaire.
Contributors: All the authors designed the study concept and design, wrote the protocol and
collected the data. SR and FM conducted the analyses. SR wrote the first draft. All authors
commented on this draft and contributed to the final version. All authors had full access to all
data (including statistical reports and tables) in the study and can take responsibility for the in-
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tegrity of the data and the accuracy of the data analysis. SVR and JOL equally contributed to
this article. Lucélia Campinho, Susana Vilar Santos and Vasco Duarte contributed to the ques-
tionnaire validation and data collection. SR and FM are the study guarantors.
Funding: This study did not receive any external funding
Competing interests: All authors have completed the ICMJE uniform disclosure form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
Ethical approval: Ethical approval was obtained from the City Council of Vila Nova de Fama-
licão, in the context of the program Aproximar, as required by national legislation.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the manu-
script is an honest, accurate, and transparent account of the study being reported; that no im-
portant aspects of the study have been omitted; and that any discrepancies from the study as
planned have been registered.
Data sharing: questionnaire available on request to the corresponding author.
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References
1. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS,
Weitzman M, Green L. Report to the Task Force on the Care of Children by Family Physicians. Washington, DC. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care in collaboration with the American Academy of Pediatrics Center for Child Health Research; 2005.
2. Bazemore AW, Makaroff LA, Puffer JC, Parhat P, Phillips RL, Xirali IM, Rinaldo J. Declining Numbers of Family Physicians are Caring for Children. Journal of the American Board of Family Medicine 2012; 25 (2): 139-140.
3. Makaroff LA, Xierali IM, Petterson SM, Shipman SA, Puffer JC, Bazemore AW. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce 2014; 12 (5): 427-431.
4. Jakubowski E, Busse R. Health Care Systems in the EU: a comparative study. European Parliament. Luxemburg, 1998.
5. PORDATA, Base de Dados Portugal Contemporâneo. Médicos: não especialistas e especialistas por especialidade – Portugal. Available on: http://www.pordata.pt/Municipios/Médicos+não+especialistas+e+especialistas+por+algumas+especialidades-441(accessed on 5 September 2015).
6. PORDATA, Base de Dados Portugal Contemporâneo. Taxa bruta de natalidade em Portugal. Available on: http://www.pordata.pt/Portugal/Taxa+bruta+de+natalidade-527 (accessed on 5 September 2015).
7. Direção Geral de Saúde. Programa Nacional de Saúde Infantil e Juvenil. Portugal, Lisbon. Direção Geral de Saúde 2013; 10/2013: 9-11
8. Direção Geral de Saúde. Programa Nacional de Vacinação 2017. Portugal, Lisbon. Direção Geral de Saúde 2017; 16/2016.
9. Gabinete de Estratégia e Planeamento. Carta Social. Resposta Social: Creche – Equipamentos existentes no Distrito de Braga, Concelho de Vila Nova de Famalicão. Available on: http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false (accessed on 5 September 2015).
10. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. Posrtugal, Lisbon 2015; 197-200.
11. Câmara Municipal de Vila Nova de Famalicão. Jardins-de-infância. Available on: http://www.cm-vnfamalicao.pt/_jardins_de_infancia_2 (accessed on 5 September 2015).
12. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 2005; 83(3): 457–502.
13. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. The Journal of Family Practice 1998; 47(2):105-9.
14. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. Medicare costs in urban areas and the supply of primary care physicians. The Journal of Family Practice 1996; 43(1):33-9.
15. Doescher MP, Franks P, Saver BG. Is family care associated with reduced health care expenditures? he Journal of Family Practice 1999; 48(8):608-14.
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STROBE Statement
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
– Page 2 (Design: cross sectional study)
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found – Page 2
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported –
Page 4 (Introduction – First, second and third paragraphs)
Objectives 3 State specific objectives, including any prespecified hypotheses – Page 4
(Introduction – Fourth paragraph)
Methods
Study design 4 Present key elements of study design early in the paper – Page 4 (Methods: study
design)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection – Page 5 (Setting and study design – first
and second paragraphs; Participants – first paragraph)
Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants – Page 5 (Setting and study design –first and second
paragraph) and Page 6 (first paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable – Page 6 (Statistical methods –
first paragraph)
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there is
more than one group – Page 4 (Methods: study design), Page 6 (Variables).
Bias 9 Describe any efforts to address potential sources of bias
Information bias – Page 5 (Participants – first paragraph)
Selection bias – Page 5 (Setting and study design –second paragraph)
Study size 10 Explain how the study size was arrived at – Page 5 (Setting and study design –
second paragraph)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why – Page 6 (Statistical methods)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding -
Page 6 (Statistical methods)
(b) Describe any methods used to examine subgroups and interactions - Page 6
(Statistical methods – third paragraph)
(c) Explain how missing data were addressed - Page 6 (firts paragraph) and Page 7
(Results –first paragraph)
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy - Page 5 (Setting and study design –second paragraph)
(e) Describe any sensitivity analyses – not applicable
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed - Page 7 (Figure 1)
(b) Give reasons for non-participation at each stage - Page 7 (Figure 1)
(c) Consider use of a flow diagram - Page 7 (Figure 1)
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders – Page 8 (table 1) and Results – second paragraph
(b) Indicate number of participants with missing data for each variable of interest – Page 7
(Results –first paragraph).
Cross-sectional study—Report numbers of outcome events or summary measures - Page 7-8:
results
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included - Page 9 (first paragraph and table 2)
(b) Report category boundaries when continuous variables were categorized –Page 8 (table 1)
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period - not applicable
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses - not applicable
Discussion
Key results 18 Summarise key results with reference to study objectives – Page 10 (Discussion – first and
second paragraphs)
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias – Page 11 (Strengths and
limitations)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence – Page 10 (Discussion –
second paragraph) and Page 11 (Conclusions and implications for future research and
practice)
Generalisability 21 Discuss the generalisability (external validity) of the study results - Page 11 (Conclusions and
implications for future research and practice)
Other information
Funding 22 No funding – page 12
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Is healthy children surveillance being duplicated by Family
Physicians and Pediatricians? A cross sectional study in
Portugal.
Journal: BMJ Open
Manuscript ID bmjopen-2017-015902.R1
Article Type: Research
Date Submitted by the Author: 21-Jul-2017
Complete List of Authors: Rebelo, Susana; Family Health Unit S. Miguel-o-Anjo Velho Rua, Sofia; Family Health Unit Ribeirão d´Orey Leça, Joana ; Family Health Unit Terras do Ave Couto, Ana; Family Health Unit S. Miguel-o-Anjo Teixeira, Rute; Family Health Unit Serzedelo Firmino-Machado, João; EPIUnit; Unidade de Saúde Pública ACeS Porto Ocidental
<b>Primary Subject Heading</b>:
General practice / Family practice
Secondary Subject Heading: Paediatrics
Keywords: Pediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice
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Is healthy children surveillance being duplicated by Family Physicians
and Pediatricians? A cross sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João
Firmino-Machado6
Sofia Velho Rua and Joana d’Orey Leça equally contributed to this article.
1 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Susana Rebelo Family Medicine Res-
ident.
2 Family Health Unit Ribeirão, Northern Regional Health Administration, Rua da Extensão de
Saúde, 4760-715 Ribeirão, Portugal, Sofia Velho Rua Family Medicine Resident.
3 Family Health Unit Terras do Ave, Northern Regional Health Administration, Rua do
Pavilhão, 4765-628 Delães, Portugal, Joana d’Orey Leça Family Medicine Resident.
4 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine
Assistent.
5 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Rute Teixeira Family Physician
Assistent.
6 Western Oporto Public Health Unit, Northern Regional Health Administration, Rua de Vila
Nova 503, 4100 Porto, Portugal, João Firmino Machado Public Health Resident.
Corresponding to: S Rebelo [email protected]
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Abstract
OBJECTIVES: To determine if children attend the Family Physician (FP) or the FP/Pediatrician
for their surveillance consultations, as well as the variables associated with parents’ choice
between the two physicians.
DESIGN: Cross sectional study.
SETTING: Public, semi-private and private kindergartens in the city of Vila Nova de Famalicão
(Portugal).
PARTICIPANTS: Parents of children enrolled in the selected kindergartens, aged 6 years old or
less, without chronic diseases.
MAIN OUTCOME MEASURES: Proportion of children attending the FP or FP/Pediatrician for
their surveillance consultations. Association between the chosen Physician and
sociodemographic and household variables (parents´ age, educational level, professional
situation and marital status; household net income; number of children; child´s age; presence of
private health insurance). Assess the parents' perception of clinical knowledge and
accessibility, regarding the Family Physician and the Pediatrician.
RESULTS: A total of 697 children were included in the analysis: 30.6% attended only the FP
and 69.4% attended both the FP and the Pediatrician. Using a multivariable binary logistic
regression, the mother´s age (OR=1.06, 95% CI 1.01-1.12), higher educational level (OR=2.11,
95% CI 1.27–3.52), household net income higher than 2000 euros (OR=5.17, 95% CI 1.02–
26.17), private health insurance (OR=4.16, 95% CI 2.51–6.90), number of children (OR=0.56,
95% CI 0.40–0.78) and the child’s age (OR=0.98, 95% CI 0.97–0.99) were statistically
associated with attending both the FP and the Pediatrician. Parents of children who attended
only FP rated the FP with a higher accessibility and knowledge mean score than those who
consulted both physicians (2.91 versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001).
CONCLUSIONS: Our data shows that 70% of our sample simultaneously attended a FP and a
Pediatrician. Family Physicians are equally qualified to provide medical care to healthy children
but this information is not properly transmitted to the general population.
Keywords: Pediatric Assistant, Family Physician, Infant, Preschool Child, Primary
Health Care, Family Practice.
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Strengths and limitations of this study
- To our knowledge, this was the first study addressing the factors associated with par-
ents’ choice in the medical care of their children
- The study did not include any Pediatrician as an author or collaborator and it was de-
signed based on the FP´s perspective.
- Our study has an adequate sampling, taking into consideration the three existing school
types: public, semi-private and private.
- We could only determine the variables associated with attending the FP or the Pediatri-
cian, but not the causes of this decision.
- We were able to confirm that there is in fact a substantial duplication of care in our
children surveillance.
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Introduction: According to the Robert Graham Center, in the United States, the ratio of children’s health care
provided by Family Physicians (FPs) decreased by about 33% between 1992 and 2002, from
one in four children to one in six.1,2 At the same time, there was an increase in the number of
visits provided by Pediatricians. FPs provide care to approximately 20% of the children between
birth and 5 years of age and increases to nearly 50% for adolescents, compared with 78% and
44%, respectively, in the case of the Pediatricians.1
FPs located in rural and underserved urban areas are more likely to provide care to children than
those in areas with higher pediatrician density.2,3 Children without health insurance or with
public health insurance are also more likely to be attended by FPs.1 Regarding the physician’s
characteristics, younger age and female sex are positively associated with medical care being
provided by FPs.3
Currently, the Portuguese health care system is characterized by two coexisting systems: the
public universal National Health Service (NHS) and the private sector. The latter includes
private insurance schemes for certain professions (health subsystems) and voluntary health
insurance. People can also have access to the private care without any insurance, paying the
total costs of the care provided. 4-5
The NHS is accessible to all residents in Portugal and provides primary and secondary health
care. It is financed mainly through taxation and tends to be free of charge, but co-payments can
be charged taking into account citizens’ social and economic conditions. However, there are
certain types of consultations free of charge regardless of individual income. This applies to all
children consultations in the NHS until the age of 18 years old.5
The National Program for Child and Juvenile Health establishes 18 surveillance consultations
provided by Primary Care at specific ages, 13 of them on the first 6 years of life.6 Additionally,
there is a Portuguese National Vaccination Plan7, which is free of charge and only accessible
through the primary care of NHS.
Primary health care physicians have a four-year residency training which includes Pediatrics
rotation in secondary care and the normal surveillance of children included in the Family
Physician residency program8. This training enables FPs to surveille healthy children and
identify any disorders that can be either treated in primary care or that require referral to
Pediatrics in secondary care.
In the Portuguese NHS Pediatricians work in secondary care and although they are also
qualified to follow healthy children, they mainly assume this role in the private sector.
There is no official data regarding the proportion of children followed simultaneously by FPs in
the NHS and by Pediatricians in private sector, but it is clear from daily practice that this choice
has been rising in the past years, which leads to duplicated care of healthy children.
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According to the national health survey of 2005/2006, 31,1% of children under fifteen years old
are followed by Pediatrician in private sector9. In 2016, in the city of Vila Nova de Famalicão,
the proportion of children with adequate surveillance by FPs in the first year of life was 80%
and 79,3% in the second year of life.10
The use of multiple care providers is associated with poor continuity of care and excess costs to
the health care system. 11
Therefore, the main objectives of our study were to determine if children attend the FP or the
FP/Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the two physicians.
This takes particular importance since it was the first study to be done on this matter, as far as
we know.
METHODS:
Study design
This was a cross sectional study. In order to determine the factors associated with parents’
choices in the medical care of their children, a questionnaire was designed by the investigators
which is available in the supplementary annex, along with the protocol.
Ethical approval was obtained from the City Council of Vila Nova de Famalicão regarding the
public institutions and by the directors of the private and semi-private kindergartens, as required
by national legislation.
Setting and Study size
The study population comprised all children up to and including those with 6 years of age,
enrolled in public, semi-private and private kindergartens in the city of Vila Nova de Famalicão,
a county in the north of Portugal.
According to national statistics, in September of 2015, there were 4989 children enrolled in the
kindergartens in the city of Vila Nova de Famalicão.12-13 We determined a minimum sample size
of 536 valid questionnaires using OpenEpi, considering a 50% proportion of children being
attended simultaneously by FPs and Pediatricians, a confidence interval (CI) of 95% and a
design effect of 1.5. A conservative approach, using a 50% prevalence, was considered because
no evidence was available on the proportion of children simultaneously attended by FPs and
Pediatricians, at a national level. We considered that the number of delivered questionnaires
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should be three times greater in order to deal with non-delivered questionnaires and the
exclusion criteria, that could not be anticipated. At the time, this county had 89 kindergartens,
47 were public, 29 semi-private and 13 were private.14 We used a random sample that was
stratified by school type – public, semi-private, private. Strata weights were calculated using the
number of students in each specific stratum and the total number of students in all schools. In
each strata, schools were considered as sampling units and were randomly selected with
selection probabilities proportional to the number of students. In each stratum, school selection
process ended when the total number of children was superior to the determined sample size, for
each school type. For each school, all the parents were invited to participate.
Participants
Parents of children from the selected kindergartens were personally invited to participate and
the purpose of the study was explained to them by the teachers, who were previously trained by
the investigators. The parents who accepted to participate signed an informed consent and
received a questionnaire, delivered by the preschool teachers between April and May of 2016.
Surveys were preferably answered at home by both parents. It was guaranteed the anonymity
and confidentiality of the data of all the participants, as they placed the unidentified
questionnaires in a sealed box. They were then collected by the investigators in June 2016.
We excluded the following children: those with chronic diseases followed by Pediatricians in
public hospitals; those up to 2 years old who had a Pediatrician but did not attend their services
in the last year, and those older than 2 years old that did not have a consultation in the last two
years. We also excluded children who did not have a FP and those who had a FP but did not
have adequate surveillance. Based on the National Program for Child and Juvenile Health6,
children are expected to attend nine surveillance consultations during the first two years of life,
and once a year until the age of 6 years old. Consequently, we established inadequate
surveillance as attending less than 80% of the consultations for children up to 2 years old, and
not attending the FP in the last 2 years for older children in Primary Care. Surveys that were
incomplete (under 80% of answered questions) were not considered for data analysis.
Variables and data collection instrument
The questionnaire consisted of two parts: the first comprised direct questions about the socio-
demographic characteristics related to parents, children and the household. The second part
consisted of statements about accessibility and knowledge, regarding the Family Physician and
the Pediatrician, to be rated according to a Likert scale. This scale includes five ordered re-
sponse levels varying between 1 and 5, measuring either negative, neutral or positive response
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to a statement. There were three questions about the clinical knowledge and four about the ac-
cessibility regarding each physician. To evaluate knowledge, parents were asked about their
perception for pediatric surveillance and acute/urgent disease management skills for both physi-
cians. Accessibility was assessed with questions about appointment scheduling (urgent, surveil-
lance and after working hours consultations), and the possibility to establish telephone contact
with the physicians.
Content validity was tested with eligible patients and minor modifications were implemented.
Data obtained by this process was not included in data analysis.
We included 13 sociodemographic and household variables in the analyses: parents’ age,
education level, professional situation and marital status; household size and net income;
number of children; child´s age and health insurance situation. Additionally, two more variables
were included, accessibility and clinical knowledge, related to the FP or Pediatrician.
Statistical methods
For statistical analysis, responders were divided in two groups: children that attended only the
Family Physician (FP group) and children that attended both the Family Physician and the
Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages, and continuous variables as
means and standard deviations.
Differences between FP and FP/Pediatrician groups’ characteristics were tested using Chi-
squared test for categorical variables and independent two-sample t-test for continuous
variables. Multivariable binary logistic regression model was used to determine the variables
associated with FP or FP/Pediatrician group. This model included as independent variables
those that were clinically supported. The variables father´s age and household size were not
included as they are suspected to be highly correlated, contributing to model multicollinearity.
Model goodness-of-fit was accessed using Nagelkerke R2 and Hosmer and Lemeshow test.
Perceptions of accessibility and knowledge were compared between FP and FP/Pediatrician
groups using independent t-tests. Additionally, accessibility and knowledge about the Family
Physician and Pediatrician were compared using a paired t-test, only for children who belonged
to the FP/Pediatrician group.
The sample was treated as a complex sample, considering the processes of stratification and
clustering, and using adequate weighting of cases for all statistic analysis.
Statistical analysis was performed with SPSS v23.0 and an α=0.05 was considered.
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RESULTS
A total of 697 questionnaires were considered for the analysis (Fig 1), 213 (30.6%) from the FP
group and 484 (69.4%) from the FP/Pediatrician group. The global missing data was 1,2% and
for each individual variable inferior to 3%.
Table 1 summarizes the sociodemographic and household characteristics of the participants
involved in the study. We found that the differences between the two groups for all the variables
were statistical significant, except for the father´s age. Higher education was more frequent in
the FP/Pediatrician group (42.3% versus 10.4% for the mother, p<0.001, and 24.9 % versus 5.4
% for the father, p<0.001). Active professional status was more frequent in FP/Pediatrician
group compared to the FP group (90% versus 78.3% for the mother, p<0.001, and 94.8% versus
86.8% for the father, p<0.001). Higher incomes were also more frequent in the Pediatrician/FP
group, with 71.3% having a monthly net income of 1000 euros (847£; 2245$) or more, com-
pared with only 36.3% in the FP group. Additionally, 45.1% of the children in the
PF/Pediatrician group and only 13.3% in the FP group had a private health insurance (p<0.001).
Table 1| Sociodemographic and household characteristics of the participants (n=697)
Total
n= 697
FP group
n= 213
FP/Pediatrici
an group
n= 484
p-
value
Mother’s age (years)
Mean ± SD
34.48 ± 5.73
33.48 ± 5.73
34.75 ± 4.46
<0.001
Mother’s education
Without higher education
With higher education
468 (67.4%) 226 (32.6%)
190 (89.6%) 22 (10.4%)
278 (57.7%) 204 (42.3%)
<0.001
Mother’s professional situa-
tion
Not active
Active
94 (13.5%) 600 (86.5%)
46 (21.7%)
166 (78.3%)
48(10.0%)
434 (90.0%) <0.001
Mother’s marital status
Single
Divorced/separated
Married/cohabiting couples
56 (8.1%)
31 (4.5%)
608 (87.5%)
27 (12.7%) 16 (7.5%)
170 (79.8%)
29 (6.0%)
15 (3.1%)
438 (90.9%)
<0.001
Father’s age (years)
Mean ± SD
36.27 ± 6.04
36.27 ± 6.04
36.84 ± 4.91
0.109
Father’s education
Without higher education
With higher education
556 (80.9%) 131 (19.1%)
194 (94.6%)
11 (5.4%)
362 (75.1%) 120 (24.9%)
<0.001
Father’s professional situation
Not active
Active
52 (7.6%)
634 (92.4%)
27 (13.2%)
177 (86.8%)
25 (5.2%)
457 (94.8%)
<0.001
Father’s marital status
Single
Divorced/separated
Married/ cohabiting couples
51 (7.4%) 35 (5.1%)
602 (87.5%)
23 (11.2%) 15 (7.3%)
167 (81.5%)
28 (5.8%) 20 (4.1%)
435 (90.1%)
<0.001
Household net income*
≤500€
501 to 999€
39 (5.8%)
225 (33.5%)
24 (11.8%)
106 (52.0%)
15 (3.2%)
119 (25.5%) <0.001
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*500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$;
†Number of people living in the same house. ‡Total number of children of both parents. SD: standard deviation; FP: Family Physician.
We adjusted a binary logistic regression considering as dependent variable attending a FP or
attending FP/Pediatrician, and as independent variables all the ones presented on Table 1 except
father´s age and household as they are suspected to be highly correlated, contributing to model
multicollinearity, and the parents´s marital state due to lack of clinical relevance. Mother´s age
and educational level, household net income higher than 2000 euros, private health insurance,
number of children and children´s age remained statistically associated with attending both
physicians, with an odds ratio (OR) of 1.06 for the mother´s age (95% CI 1.01-1.12); 2.11 for
the mother's educational level (95% CI 1.27 – 3.52); 5.17 (95% CI 1.02 – 26.17) for household
net income higher than 2000 euros when compared with lowest income (500€); 4.16 for having a
private health insurance (95% CI 2.51 – 6.90); 0.56 for the number of children (95% CI 0.40 –
0.78) and 0.98 for the child´s age in months (95% CI 0.97 – 0.99).
Table 2| Binary logistic regression for determination of variables associated with FP and FP/Pediatrician group.
Independent variables
OR
95% CI for OR
Mother´s age (years) 1.06 1.01-1.12
Mother’s education
Without higher education
With higher education
1
2.11
—
1.27 – 3.52
Mother’s professional situation
Not active
Active
1
1.90
—
0.98 – 3.70
Father’s education
Without higher education
With higher education
1
2.14
—
0.64 – 7.19
Father’s professional situation
Not active
Active
1
1.97
—
0.86 – 4.55
Household net income*
≤500€
501 to 999€ 1000 to 1999€
≥2000€
1 0.79 1.41 5.17
— 0.33 – 1.92 0.49 – 4.04
1.02 – 26.17
1000 to 1999€
≥2000€ 318 (47.4%) 89 (13.3%)
70 (34.3%) 4 (2.0%)
248 (53.1%) 85 (18.2%)
Private health insurance
No
Yes
449 (64.6%) 246 (35.4%)
184 (86.8%) 28 (13.2%)
265 (54.9%) 218 (45.1%)
<0.001
Household size†
Mean ± SD
3.79 ± 0.79
3.79 ± 0.79
3.56 ± 0.74
<0.001
Number of children‡
Mean ± SD
1.83 ± 0.77
1.83 ± 0.78
1.57 ± 0.66
<0.001
Child’s age (months)
Mean ± SD
51.41 ± 18.64
52.41± 18.67
45.44 ± 20.19
<0.001
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Private health insurance
No
Yes
1
4.16
—
2.51 – 6.90
Number of children‡ 0.56 0.40 – 0.78
Child’s age (months) 0.98 0.97 – 0.99
Hosmer and Lemeshow test p=0.704
R2 (Nagelkerke)
36%
ROC Curve AUROC = 0.81 (0.78 – 0.85), p<0.001 *500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; ‡Total number of children of both parents. ROC: Receiver Operating Characteristic. AUROC: Area Under the ROC Curve; OR: Odds Ratio. CI: Confidence interval. The FP group was considered as the reference group for the logistic regression. The variables father´s age and household size were not included as they are suspected to be highly correlated, contributing to model multicolline-arity. The parents’ marital status was not included due to lack of clinical relevance.
Regarding the parents’ perception about accessibility and clinical knowledge of the physicians,
we found statistical differences between the two groups (Table 3). The FP group rated the FP with
a higher accessibility and knowledge mean score comparing with FP/Pediatrician group (2.91
versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001). In the FP/Pediatrician group, the mean
score of accessibility and knowledge was significantly higher for the Pediatrician comparing
with the FP (4.29 versus 2.53, p<0.001, and 4.11 versus 3.85, p<0.001).
Table 3| Parents’ perception on accessibility and knowledge of the Family Physician and the Pediatrician.
Items about Knowledge related to
the: Items about Accessibility related to
the:
Family Physician Pediatrician Family Physician Pediatrician
Participants with Family Physician
4.11 ± 0.87* ------ (a)
2.91 ± 1.10* ------
(a)
Participants with Family Physician and Pediatrician
3.85 ± 0.87*
4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.77*
*mean ± standard deviation; (a) – did not have a Pediatrician
Discussion
In our study, only about 30% of the children attended exclusively the FP for surveillance con-
sultations, and 70% of the sample attended both the FP and the Pediatrician.
We found that the mother´s age and her educational level, household net income, private health
p<0.001 p<0.001 p<0.001 p<0.001
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insurance, number of children and the child’s age were associated with attending both the FP
and the Pediatrician. Variables with higher impact in the parents’ choice were household net
income higher than 2000 euros (OR =5.17, 95% CI 1.02 – 26.17), followed by having a private
health insurance (OR= 4.16, 95% CI 2.51 – 6.90). Both mother´s age and her educational level
were statistically associated with attending both physicians. However, father´s age and his edu-
cational level were not associated with the parents’ choice. This could be explained by social
and cultural influences in Portugal, where the mother is still recognized as the center of nurture
and care in the family life. Additionally, the number of children and the child´s age were also
associated with the parents’ choice. As the number of children increases within the household
and children grow older, there is an increasing odd of being followed only by the FP for surveil-
lance consultations. We think this may be explained by a higher experience and knowledge of
the parents about the child’s health. Furthermore, economic reasons may influence this choice
as the number of children grows. Our results are supported by the Robert Graham Center study1
findings: the proportion of children attending the Pediatrician decreases as the child grows older
and children with private health insurance are more likely to attend the Pediatrician. Regarding
parents’ perception of accessibility and clinical knowledge of the Family Physician and the Pe-
diatrician, we found statistical differences between the two groups. Parents who attended both
physicians rated the FP with lower accessibility and knowledge than those who consulted only
the FP.
Strengths and limitations
To our knowledge, there are no previous studies available regarding the factors associated with
parents’ choice in the medical care of their children, so this is the first one addressing this im-
portant subject. Other strengths of our study are an adequate sampling, taking into consideration
the three existing school types: public, semi-private and private.
The main limitation was that we could only determine the variables associated with attending
the FP or the Pediatrician, but not the causes of this decision because causality can not be evalu-
ated due to the study design.
Conclusions and implications for future research and practice
We identified variables associated with the parents’ choice in the medical care of their children,
with household net income and private health insurance being the most relevant ones.
Our data shows that Family Physicians still play an important role on children’s follow-up, even
though approximately 70% of our sample simultaneously attended a Pediatrician, which can
translate into a duplication of care and costs.
Unlike Pediatricians, the role of FPs is still unclear to most parents since they rated the FP with
a lower clinical knowledge mean than the Pediatrician. However, Family Physicians and Pedia-
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tricians are equally qualified to provide medical care to children without chronic diseases, with
the advantage that costs associated with the same surveillance consultations are lower when
carried out in Primary Health Care.15-18 Moreover, these facts should be advertised and included
in health care promotion and education that is provided to parents and general population.
Additional investigation is relevant to understand if children’s medical care provided simulta-
neously by a Pediatrician and a FP is associated with health benefits and higher public health
costs when compared to medical care provided exclusively by the FP.
Footnotes
We thank the City Council of Vila Nova de Famalicão, the institutions that participated in the
study and all the parents who kindly completed the questionnaire.
Contributors: SR, SVR, JOL, AC, RT and JFM designed the study concept and design, wrote
the protocol and collected the data. All authors contributed to the questionnaire validation and
data collection. SR and FM conducted the analyses. All authors helped to draft the manuscript
and have read and approved the final manuscript. All authors had full access to all data (includ-
ing statistical reports and tables) in the study and can take responsibility for the integrity of the
data and the accuracy of the data analysis. SVR and JOL equally contributed to this article.
Carolina Gonçalves contributed to the study design. Lucélia Campinho, Susana Vilar Santos
and Vasco Duarte contributed to the questionnaire validation and data collection. SR and FM
are the study guarantors.
Funding: This study did not receive any external funding
Competing interests: None declared.
Contributorship Statement: All authors have completed the ICMJE uniform disclosure form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
Ethical approval: Ethical approval was obtained from the City Council of Vila Nova de Fama-
licão, in the context of the program Aproximar, as required by national legislation.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the manu-
script is an honest, accurate, and transparent account of the study being reported; that no im-
portant aspects of the study have been omitted; and that any discrepancies from the study as
planned have been registered.
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Data sharing: questionnaire available on request to the corresponding author.
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References
1. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS,
Weitzman M, Green L. Report to the Task Force on the Care of Children by Family Physicians. Washington, DC. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care in collaboration with the American Academy of Pediatrics Center for Child Health Research; 2005.
2. Bazemore AW, Makaroff LA, Puffer JC, Parhat P, Phillips RL, Xirali IM, Rinaldo J. Declining Numbers of Family Physicians are Caring for Children. Journal of the American Board of Family Medicine 2012; 25 (2): 139-140.
3. Makaroff LA, Xierali IM, Petterson SM, Shipman SA, Puffer JC, Bazemore AW. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce 2014; 12 (5): 427-431.
4. Jakubowski E, Busse R. Health Care Systems in the EU: a comparative study. European Parliament. Luxemburg, 1998.
5. Barros P, Machado S, Simões J. Portugal: Health system review. Health Sys-tems in Transition, 2011, 13(4):1–156.
6. Direção Geral de Saúde. Programa Nacional de Saúde Infantil e Juvenil. Portugal, Lisbon. Direção Geral de Saúde 2013; 10/2013: 9-11
7. Direção Geral de Saúde. Programa Nacional de Vacinação 2017. Portugal, Lisbon. Direção Geral de Saúde 2017; 16/2016.
8. Ministério da Saúde. Diário da República, 1.ª série, N.º 36 — 20 de fevereiro de 2015
9. Entidade Reguladora da Saúde. Caracterização do Acesso dos Utentes a Cuidados de Saúde Infantil e Juvenil e de Pediatria. Março 2011
10. SIARS platform. P01.02.02.R01. Relatório de Indicadores ACeS no Período em análise (accessed on 3 july 2017).
11. Macpherson A,Kramer M, Ducharme F, Yang H, Bélanger F. Doctor shopping before and after a visit to a paediatric emergency department. Paediatr Child Health. 2001 Jul-Aug; 6(6): 341–346.
12. Gabinete de Estratégia e Planeamento. Carta Social. Resposta Social: Creche – Equipamentos existentes no Distrito de Braga, Concelho de Vila Nova de Famalicão. Available on: http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false (accessed on 5 September 2015).
13. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. Posrtugal, Lisbon 2015; 197-200.
14. Câmara Municipal de Vila Nova de Famalicão. Jardins-de-infância. Available on: http://www.cm-vnfamalicao.pt/_jardins_de_infancia_2 (accessed on 5 September 2015).
15. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 2005; 83(3): 457–502.
16. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. The Journal of Family Practice 1998; 47(2):105-9.
17. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. Medicare costs in urban areas and the supply of primary care physicians. The Journal of Family Practice 1996; 43(1):33-9.
18. Doescher MP, Franks P, Saver BG. Is family care associated with reduced health
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care expenditures? he Journal of Family Practice 1999; 48(8):608-14. Figure Legends:
Fig 1| Flowchart showing the sample selection.
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Fig 1| Flowchart showing the sample selection.
210x297mm (300 x 300 DPI)
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua , Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino-Machado.
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Authors:
1- Susana Rebelo (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 2- Sofia Velho Rua (Family Medicine Resident in Family Health Unit Ribeirão) 3- Joana d’Orey Leça (Family Medicine Resident in Family Health Unit Terras do Ave) 4- Ana Faria Couto (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 5- Rute Teixeira (Family Physician in Family Health Unit S. Miguel-o-Anjo) 6- Joõa Firmino-Machado (Public Health Resident in WesternOportoPublicHealthUnit)
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Index
LIST of ABBREVIATIONS.........................................................................................................................................4
ABSTRACT........................................................................................................................................................................5
INTRODUCTION.............................................................................................................................................................6
OBJECTIVES.....................................................................................................................................................................7
POPULATION...................................................................................................................................................................7
SAMPLE..............................................................................................................................................................................7
Sampling technique..................................................................................................................................7Sample size...............................................................................................................................................8
PARTICIPANTS...............................................................................................................................................................8
VARIABLES....................................................................................................................................................................10
METHODS........................................................................................................................................................................12
Study location.........................................................................................................................................12Type, duration and study period.............................................................................................................12Study design...........................................................................................................................................12Pilot study..............................................................................................................................................12
COLLABORATOR’S TRAINING...........................................................................................................................13
STATISTICAL ANALYSIS.......................................................................................................................................13
STUDY TIMELINE:......................................................................................................................................................14
MANAGEMENT AND BUDGET............................................................................................................................15
AUTHORS........................................................................................................................................................................15
REFERENCES.................................................................................................................................................................15
APPENDIX I: QUESTIONNAIRE...........................................................................................................................17
APPENDIX II: INFORMED CONSENT...............................................................................................................23
Informed Consent Form for Study Participation....................................................................................23
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LIST OF ABBREVIATIONS
ACeS – Agrupamento de Centros de Saúde
FP – Family Physician
OR – Odds Ratio
PHC - Primary Health Care
USF – Unidade de Saúde Familiar
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua, Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino Machado.
ABSTRACT
Introduction: In the United States, the ratio of children’s health care provided by Family
Physicians (FPs) decreased by about 33% between 1992 and 2002, from one in four children to
one in six, and, at the same time, there was a significant growth in the number of visits provided
by Pediatricians.
Objectives: To determine if children attend the FP or the Pediatrician for their surveillance
consultations, as well as the variables associated with the parents’ choice between the FP and the
Pediatrician.
Methods and Analysis: Cross sectional analytical study, with an expected duration of one year
and two months. The study population will comprise all parents of pre-school children enrolled
in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate
in the study. The kindergartens will be randomly selected until a statistically significant sample
is obtained. The authors will contact each institution and assess the interest in participating in the
study. Between April and May 2016 all parents of the selected institutions will be invited to
participate in the study. They will have to sign an informed consent and receive a questionnaire
that was created by the investigators and that will be validated by a previous pilot study. The filled
questionnaires will be placed in a sealed box and the investigators will collect them in June 2016.
Statistical analysis will be performed with SPSS v23.0.
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INTRODUCTION
Primary Health Care (PHC) is ideally the first point of contact that a patient has with the
health care system. It has a key role in care providing as it assumes a longitudinal continuity of
care, from birth till death, and a holistic approach of the patient, taking into account his familiar,
social, economic, professional, cultural and many other aspects that comprise his context.
The Family Physician attends patients from both sexes, all age groups, ethnicities, races
and socio-economic levels. However, the age group that includes children from 0 to 18 years
assumes particular importance in PHC. It is a priority group that justifies a bigger effort and
willingness by health providers.
In the United States, the ratio of children’s health care provided by Family Physicians
(FPs) decreased by about 33% between 1992 and 2002, from one in four children to one in six (1;
2) and, at the same time, there was a significant growth in the number of visits provided by
Pediatricians. FPs provide care to approximately 16% of the children between birth and 5 years
of age, compared with 73% in the case of the Pediatricians (1).
FPs located in rural and underserved urban areas are more likely to provide care to
children than those in areas with higher pediatrician density (2; 3). Children without private health
insurance or with public health insurance are also more likely to be attended by FPs (1). Regarding
the physician’s characteristics, younger age and female sex are positive predictors for medical
care being provided by FPs (3).
In Portugal, from 1992 to 2015 the number of Pediatricians and FPs(4) more than doubled
and the birth rate declined from 11,5 to 8,3 live births per 1000 persons (5). The National Program
for Child and Juvenile Health (6) establishes 18 surveillance consultations at specific ages, 13 of
them on the first 6 years of life. These consultations are intended to be done in the Primary Health
Care system but, even though there are no official numbers, it is clear that the number of children
who are simultaneously attended by a Pediatrician in private care is rising.
Therefore, the main objectives of our study are to determine if children attend the FP or
the Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the FP and the Pediatrician. This takes particular importance since it is
the first study to be done on this matter.
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OBJECTIVES
1. To determine the variables related to the parents’ choice of the physician (Family
Physician or Pediatrician) for the surveillance consultations of their children.
2. To determine if there is an association between the choice of the physician and the
following variables:
• Parents´ age
• Parents´ educational level
• Parents´ professional situation
• Parents´ marital status
• Household net income
• Household size
• Number of children
• Child’s age
• Presence of private health insurance
3. To assess the parents' perception of the scientific and clinical knowledge, as well as the
accessibility to the physician (FP or Pediatrician).
POPULATION Vila Nova de Famalicão is a town and municipality in the district of Braga, in the north
of Portugal. It has an area of 201.8 km² (7), distributed between 34 civil parishes (8). In 2011, the
population was 133,832 (9).
According to national statistics, in September of 2015, there were 4989 children enrolled
in the kindergartens in the municipality of Vila Nova de Famalicão. This population was
calculated using the data published in Carta Social (10) and the document “Regiões em Números
2013/2014, Volume I-Norte” (11), of the Direção Geral de Estatísticas e da Educação e Ciências.
According to those documents, there were about 1517 children attending kindergartens (10) (up to 3 years old) and approximately 3472 children in pre-school education (3-6 years) (11).
SAMPLE Sampling technique
According to the City Council of Vila Nova de Famalicão (12), there were 89 kindergartens
and pre-school in the county, of which 13 were private, 29 semi-private and 47 public.
We randomized a sample that was stratified by school type – public, semi-public, private. In each
strata, schools were considered as sampling units and were randomly selected with selection
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probabilities proportional to the number of students. For each school, all the parents were invited
to participate.
Sample size
We determined a minimum sample size of 536 valid questionnaires using OpenEpi, using a
prevalence of 50%, a confidence interval (CI) of 95% and a design effect of 1.5. At the time, this
county had 89 kindergartens, 13 were private, 29 semi-private and 47 public (12). We considered
that the number of delivered questionnaires should be three times greater in order to deal with
non-delivered questionnaires and the exclusion criteria, that could not be anticipated. We used a
random sample that was stratified by school type – public, semi-public, private. Strata weights
were calculating the number of students in each specific stratum and the total number of students
in all schools. In each strata, schools were considered as sampling units and were randomly
selected with selection probabilities proportional to the number of students. In each stratum school
selection process ended when the total number of children was superior to the determined sample
size, for each school type. For each school, all the parents were invited to participate.
PARTICIPANTS The study participants will comprise all parents, of the selected kindergartens, with children up
to and including those with 6 years old.
Inclusion criteria
• Parents of children up to and including those with 6 years old, enrolled in public, semi-
private and private kindergartens in the city of Vila Nova de Famalicão
• Parents who agree to take part in the study.
Exclusion criteria
• Children with chronic diseases followed by Pediatricians.
• Children in public hospital following.
• Children up to 2 years old who had a Pediatrician but did not attend their services in the
last year.
• Children older than 2 years old who had a Pediatrician but did not attend their services in
the last two years.
• Children who did not have a FP.
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• Children with a FP but did not had adequate surveillance
• Surveys with more than 20% of unanswered questions
Based on The National Program for Child and Juvenile Health (6), we defined inadequate
surveillance as attending less than 80% of the consultations for children up to 2 years old and not
attending the FP in the last 2 years for older children.
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VARIABLES
The study variables, their operational definition, the type and the values that the variable can take are described in detail in Table 1.
Table 1 – Operational definition, type, acceptable values and coding of the variables under study.
Variable Definition Variable type Values that the variable can take
Child´s physician Physician responsible for the surveillance consultations Categorical
nominal
FP group
FP/Pediatrician group
Mother´s age Number of years between the date of birth and the date of data collection Continuous
Mother´s educational
level
Mother’s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Mother’s professional
situation
Employment situation of mother at the time of data collection Categorical
nominal
Not active
Active
Mother´s marital
status
Mother´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Father´s age Number of years between the date of birth and the date of data collection Continuous
Father´s educational
level
Father´s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Father’s professional
situation
Employment situation of father at the time of data collection Categorical
nominal
Not active
Active
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Father´s marital
status
Father´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Household net income
Monthly net income of the household, in euros. Categorical
Ordinal
≤500€
501 to 999€
1000 to 1999€
≥2000€
Private health
insurance
Private health insurance that includes the child or child with his own private
health insurance
Categorical Yes
No
Household size Number of people living in the same house. Continuous
Number of children Total number of children of the mother and the father Continuous
Child´s age (months) Number of months between the date of birth and the date of data collection Continuous
FP’s knowledge Parents’ perception about the scientific and clinical knowledge of the FP. Categorical
Ordinal
1-5
Pediatrician’s
knowledge
Parents’ perception about the scientific and clinical knowledge of the
Pediatrician.
Categorical
Ordinal
1-5
FP’s accessibility Parents’ perception about the accessibility to the FP. Categorical
Ordinal
1-5
Pediatrician’s
accessibility
Parents’ perception about the accessibility to the Pediatrician. Categorical
Ordinal
1-5
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METHODS
Study location
Selected kindergartens and pre-schools institutions in Vila Nova de Famalicão.
Type, duration and study period
Cross sectional analytical study, with an expected duration of one year and five months
(from June 2015 to November 2016).
Study design
Parents of children enrolled in the selected kindergartens will be invited to participate and
the purpose of the study will be explained to them by the teachers, who will be previously trained
by the investigators. The parents who accept to participate will sign an informed consent and
receive a questionnaire, which will be delivered by the preschool teachers between April and May
of 2016. Surveys must be answered at home by both parents, if possible. It will be guaranteed the
anonymity and confidentiality of the data of all the participants, as they will place the unidentified
questionnaires in a sealed box. The sealed boxes will be collected by the investigators in June
2016.
In order to determine the factors associated with parents’ choices in the medical care of
their children, a questionnaire was created by the investigators (Appendix I). This consists of two
parts: the first comprises direct questions about the sociodemographic characteristics related to
parents, children and the household. The second part consists of statements about accessibility
and knowledge, regarding the Family Physician and the Pediatrician, to be rated according to a
Likert scale. This scale includes five ordered response levels varying between 1 and 5. A pilot
study will be conducted in the eligible population to test content validity.
Pilot study
A pilot study will be conducted in the eligible population to test content validity. The pilot
study will be conducted in February 2016 and it will consist on applying the questionnaire in the
eligible population followed by an interview, in a small sample (approximately 30 persons). In
the interview, it will be discussed with the participants, topics as the time necessary for the
questionnaire, the question’s format and pertinence, and all the comments that they feel
appropriate, and if necessary, changes will be made in the questionnaire to its final version.
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COLLABORATOR’S TRAINING
It will take place in a multidisciplinary meeting in every institution that accepts to
participate in the study and it will consist on presenting to the teachers the study objectives,
duration and timeline, population and the inclusion and exclusion criteria, and clarification of any
question that might occur. In every meeting, there will be at least two members of the
investigation team present.
The teachers that accept to participate will be asked to sign a declaration of commitment.
STATISTICAL ANALYSIS For statistical analysis, the sample will be divided in two groups: children that attended
only the Family Physician (FP group) and children that attended both the Family Physician and
the Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages and continuous
variables as means and standard deviations. Shapiro-Wilk test will be used to test for normality.
Differences between FP and FP/Pediatrician groups’ characteristics will be tested using qui-
square test or independent sample T-test, as appropriate. Multivariate binary logistic regression
model will be used to determine the variables associated with FP or FP/Pediatrician group. This
model will include as independent variables only those identified by univariate analysis, with p-
values <0,1.
Perceptions of accessibility and knowledge will be compared between FP and
FP/Pediatrician groups using independent T-tests. Additionally, accessibility and knowledge
about the Family Physician and Pediatrician will be compared using a paired sample T-test, only
for children who belong to the FP/Pediatrician group.
Statistical analysis will be performed with SPSS v23.0 and p<0,05 will be defined as
statistically significant.
:
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STUDY TIMELINE:
The data collection process will be held according to the following steps:
Table 1 – Study timeline
2015 2016
June - December January February March April May June July August September November
Protocol and questionnaire design
Submission to ethical approval
Contact with the director of the selected kindergartens and pre-schools
Collaborators’ training
Pilot study
Questionnaires delivery
Data analysis and results discussion
Release of the results
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MANAGEMENT AND BUDGET
The study authors are responsible for the protocol design, collaborators’ training, data
analysis and release of the results. Table 2 shows the required material and budget to the
implementation of the study. All costs of the study will be supported by the authors.
Table 2 – Study material and budget.
Material Unitary Cost (€) x Number of unites required
Cost (€)
Informed consent 0.03 x 4 x 1400 168
Questionnaires (A4) 0.03 x 6 x 1400 252
Travel expenses 200 200
Other expenses 300 300
Total cost - 920
AUTHORS
Susana Rebelo (Family Health Unit S. Miguel-o-Anjo) Ana Faria Couto (Family Health Unit S. Miguel-o-Anjo) Joana d’Orey Leça (Family Health Unit Terras do Ave) Sofia Velho Rua (Family Health Unit Ribeirão) Rute Teixeira (Family Health Unit S. Miguel-o-Anjo) Firmino Machado (Western Oporto Public Health Unit)
REFERENCES
1. Report to the Task Force on the Care of Children by Family Physicians. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS, Weitzman M, Green L. s.l. : The Robert Graham Center: Policy Studies in Family Medicine and Primary Care In collaboration with the American Academy of Pediatrics Center for Child Health Research, 2005.
2. Declining Numbers of Family Physicians are Caring for Children. Bazemore A, Makaroff L, Puffer J, Parhat P, Phillips R, Xirali I, Rinaldo J. 2012, Journal of the American Board of Family Medicine, Vols. 25, No 2, pp. 139-140.
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3. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce. Makaroff LA, Xierali IM, Petterson S, Shipman S, Puffer J, Bazemore A. 2014, Annals of Family Medicine, Vols. 12, No 5.
4. PORDATA: Base de Dados Portugal Contemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Médicos+não+especialistas+e+especialistas+por+especialidade-147.
5. PORDATA: Dados de Portugal Comtemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Taxa+bruta+de+natalidade-527.
6. Programa Nacional de Saúde Infantil e Juvenil. Direção Geral de Saúde. s.l. : Lisboa : Direção Geral de Saúde. , 2013. , Vol. Vol. nº 10/2013.
7. Camara Municipal: Vila Nova de Famalicão. Carta Educativa do Municipio de Vila Nova de Famalicão. Vila Nova de Famalicão : s.n., 2009.
8. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 05 de September de 2015.] http://www.cm-vnfamalicao.pt/_freguesias_7.
9. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_censos_2011__populacao.
10. Gabinete de Estratégia e Planeamento. Carta Social. [Online] [Citação: 5 de September de 2015.] http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false..
11. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015 : s.n.
12. Famalicão, Camara Municipal: Vila Nova de. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_jardins_de_infancia_.
13. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015.
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APPENDIX I: QUESTIONNAIRE
We would like to invite you to participate in a research study designed five Family
Physicians that work in three different health institutions in the county of Vila Nova de Famalicão
(Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-
o-Anjo) and a Public Health Physician. To that effect, your participation would consist of filling
out the questionnaire in the appendix. Its purpose is to know the factors that determine parents’
choice of the physician (Family Physician or Pediatrician) for their children’s surveillance
consultations.
It will be guaranteed the anonymity and confidentiality of the data of all the participants
and they will be used exclusively for the purpose of this study.
The authors thank you for your collaboration.
Ana Faria Couto | Family Medicine Resident in Family Health Unit Familiar S. Miguel-o-Anjo
João Firmino Machado | Public Health Resident in WesternOportoPublicHealthUnit
Joana d’Orey Leça | Family Medicine Resident in Family Health Unit Terras do Ave
Rute Teixeira | Family Physician in Family Health Unit S. Miguel-o-Anjo
Sofia Velho Rua | Family Medicine Resident in Family Health Unit Ribeirão
Susana Rebelo | Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo
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1. Age (type the number): ___________ years
2. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widow
3. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
4. Professional situation
Active
Unemployed
Retired
Student
5. Age (type the number): ___________ years
6. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widower
MOTHER'SIDENTIFICATION
FATHER'SIDENTIFICATION
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1. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
2. Professional situation
Active Unemployed
Retired
Student
Household
3. Number of household members (number of people living in your home): ___________________________
4. How many children do you have? (please take into consideration the mother and the father’s children)____________________________
5. Average monthly household income (after tax)
499 euros or less
from 500 to 999 euros
from 1000 euros to 1999 euros
2000 euros or more
6. Does your child have a private health insurance of his own? Do you have a private
health insurance that includes your child?
Yes No
7. Date of birth of your child (DD/MM/YYYY)
_____/______/__________
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8. Does your child have any chronic disease1?
Yes No I don’t know
9. Does your child have an assigned Family Physician?
Yes No
a. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
10. Does your child have a Pediatrician?
Yes No
a. If so, where?
Public Hospital Private Hospital/ Clinic b. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
1Chronic disease: disease with more than 6 months of duration, which implies more frequent medical follow-up, beyond the surveillance consultations defined in the health record of your child.
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The following questions aim to know your opinion about your Family Physician’s skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
The Family Physician is empowered to conduct surveillance consultations of my son.
The Family Physician has expertise to solve acute/urgent diseases of my son.
It is easy to schedule an appointment with the Family Physician.
It is easy to schedule an appointment on the same day in case of an acute/urgent disease with the Family Physician.
It is easy to talk by telephone with the Family Physician in case of illness.
It is easy to schedule an appointment after working hours in the Family Physician.
Surveillance by the Family Physician is important because of the knowledge that he has about the family context.
Quiz
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The following questions aim to know your opinion about the Pediatrician's skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
I think that the Pediatrician has more knowledge and clinical practice related to children than the Family Physician.
I believe that my son is best followed by a Pediatrician, regardless of the Family Physician’s quality.
I believe that children should always be followed by a Pediatrician, even if simultaneously followed by the Family Physician.
It is easy to schedule an appointment with the Pediatrician.
It is easy to schedule an appointment on the same day with the Pediatrician in case of an acute/urgent disease.
It is easy to talk by telephone with the Pediatrician in case of illness.
It is easy to schedule an appointment after working hours with the Pediatrician.
Thank you for your collaboration!
CompleteonlyifyourchildisfollowedbyaPediatricianinaprivatehospitalorclinic.
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Author’ssignatures_______________________________________________________________________________________________________________________
APPENDIX II: INFORMED CONSENT
Informed Consent Form for Study Participation
according to Declaration of Helsinki2 and Oviedo Convention3
You have been invited to participate in a research study, please read carefully all the information below. If you believe that there is an incorrect or unclear information, do not hesitate to ask for clarification. If you agree to participate, please sign this document.
Title of study: “Are healthy children attended by the family physician or the pediatrician? Determinants of an important decision”
Purpose of the Study: This is a research study designed by five Family Physicians that work in three different health institutions in the county of Vila Nova de Famalicão 8Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-o-Anjo) and a Public Health Physician. The main objective is to know the factors that determine parents’ choice of the physician (Family Physician or Pediatrician) for their children’s surveillance consultations. The study population will comprise parents of pre-school children enrolled in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate in the study. To that effect, your participation will consist of filling out an anonymous questionnaire that will be given to you by the children’s teachers.
Conditions and compensations: There will be no compensations nor prejudice for the participants. The parents’ collaboration is voluntary and, therefore, you are free to refuse to participate. Ethical approval was obtained from the City Council of Vila Nova de Famalicão, in the context of the program Aproximar, as required by national legislation.
Confidentiality and anonymity: It is guaranteed the anonymity and confidentiality of the data of all the participants and they will be used exclusively for the purpose of this study. It was requested and granted authorization of National Data Protection Commission.
The authors thank you for your collaboration.
Susana Rebelo | Family Health Unit S. Miguel-o-Anjo |[email protected] Ana F. Couto | Family Health Unit S. Miguel-o-Anjo | [email protected] João Firmino Machado | Western Oporto Public Health Unit | [email protected] Joana d’Orey Leça | Family Health Unit Terras do Ave | [email protected] Rute Teixeira | Family Health Unit S. Miguel-o-Anjo | [email protected] Sofia Velho Rua | Family Health Unit Ribeirão | [email protected]
-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o- Your signature below indicates that you have read the document and that you confirm all the following:
1. The study has been explained to you and all of your questions have been answered. 2. You understand why the study is being conducted and how it will be performed. 3. You understand that your participation is voluntary and that you can refuse to participate at any
point of the study without any kind of prejudice.
2http://portal.arsnorte.min-saude.pt/portal/page/portal/ARSNorte/Comiss%C3%A3o%20de%20%C3%89tica/Ficheiros/Declaracao_Helsinquia_2008.pdf
3http://dre.pt/pdf1sdip/2001/01/002A00/00140036.pdf
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4. You understand that anonymity and confidentiality will be guaranteed and that all data will be used exclusively for the purpose of the study.
5. You understand your rights and you voluntarily consent to your child’s participation in this study. 6. You have been told you will receive a copy of this form.
Name: … … … … … … … …... … … … …... … … … … … … … … … … … … Signature: … … … … … … … …... … … … … ... … … … … … … … … … … … … Date: …… /…… /………..
THIS IS A 2 PAGE AND DUPLICATED DOCUMENT: ONE COPY FOR THE INVESTIGATOR
AND ONE FOR THE PARTICIPANT
If illiterate: I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Print name of witness: … … … … … …… … … … … … … … Thumb print of participant Signature of witness: … … … … … …… … … … … …… … Date …… /…… /………..
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STROBE Statement
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
– Page 2 (Design: cross sectional study)
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found – Page 2
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported –
Page 4 (Introduction – First, second and third paragraphs)
Objectives 3 State specific objectives, including any prespecified hypotheses – Page 4
(Introduction – Fourth paragraph)
Methods
Study design 4 Present key elements of study design early in the paper – Page 4 (Methods: study
design)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection – Page 5 (Setting and study design – first
and second paragraphs; Participants – first paragraph)
Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants – Page 5 (Setting and study design –first and second
paragraph) and Page 6 (first paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable – Page 6 (Statistical methods –
first paragraph)
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there is
more than one group – Page 4 (Methods: study design), Page 6 (Variables).
Bias 9 Describe any efforts to address potential sources of bias
Information bias – Page 5 (Participants – first paragraph)
Selection bias – Page 5 (Setting and study design –second paragraph)
Study size 10 Explain how the study size was arrived at – Page 5 (Setting and study design –
second paragraph)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why – Page 6 (Statistical methods)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding -
Page 6 (Statistical methods)
(b) Describe any methods used to examine subgroups and interactions - Page 6
(Statistical methods – third paragraph)
(c) Explain how missing data were addressed - Page 6 (firts paragraph) and Page 7
(Results –first paragraph)
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy - Page 5 (Setting and study design –second paragraph)
(e) Describe any sensitivity analyses – not applicable
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed - Page 7 (Figure 1)
(b) Give reasons for non-participation at each stage - Page 7 (Figure 1)
(c) Consider use of a flow diagram - Page 7 (Figure 1)
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders – Page 8 (table 1) and Results – second paragraph
(b) Indicate number of participants with missing data for each variable of interest – Page 7
(Results –first paragraph).
Cross-sectional study—Report numbers of outcome events or summary measures - Page 7-8:
results
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included - Page 9 (first paragraph and table 2)
(b) Report category boundaries when continuous variables were categorized –Page 8 (table 1)
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period - not applicable
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses - not applicable
Discussion
Key results 18 Summarise key results with reference to study objectives – Page 10 (Discussion – first and
second paragraphs)
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias – Page 11 (Strengths and
limitations)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence – Page 10 (Discussion –
second paragraph) and Page 11 (Conclusions and implications for future research and
practice)
Generalisability 21 Discuss the generalisability (external validity) of the study results - Page 11 (Conclusions and
implications for future research and practice)
Other information
Funding 22 No funding – page 12
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Is healthy children surveillance being duplicated by Family
Physicians and Pediatricians? A cross sectional study in
Portugal.
Journal: BMJ Open
Manuscript ID bmjopen-2017-015902.R2
Article Type: Research
Date Submitted by the Author: 11-Sep-2017
Complete List of Authors: Rebelo, Susana; Family Health Unit S. Miguel-o-Anjo Velho Rua, Sofia; Family Health Unit Ribeirão d´Orey Leça, Joana ; Family Health Unit Terras do Ave Couto, Ana; Family Health Unit S. Miguel-o-Anjo Teixeira, Rute; Family Health Unit Serzedelo Firmino-Machado, João; EPIUnit; Unidade de Saúde Pública ACeS Porto Ocidental
<b>Primary Subject Heading</b>:
General practice / Family practice
Secondary Subject Heading: Paediatrics
Keywords: Pediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice
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Is healthy children surveillance being duplicated by Family Physicians
and Pediatricians? A cross sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João
Firmino-Machado6
Sofia Velho Rua and Joana d’Orey Leça equally contributed to this article.
1 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Susana Rebelo Family Medicine Res-
ident.
2 Family Health Unit Ribeirão, Northern Regional Health Administration, Rua da Extensão de
Saúde, 4760-715 Ribeirão, Portugal, Sofia Velho Rua Family Medicine Resident.
3 Family Health Unit Terras do Ave, Northern Regional Health Administration, Rua do
Pavilhão, 4765-628 Delães, Portugal, Joana d’Orey Leça Family Medicine Resident.
4 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine
Assistent.
5 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida
Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Rute Teixeira Family Physician
Assistent.
6 Western Oporto Public Health Unit, Northern Regional Health Administration, Rua de Vila Nova 503, 4100 Porto; EPIUnit, Rua das Taipas, 4050-600 Porto, Portugal, João Firmino Machado Public Health Resident.
Corresponding to: S Rebelo [email protected]
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Abstract
OBJECTIVES: To determine if children attend the Family Physician (FP) or the FP/Pediatrician
for their surveillance consultations, as well as the variables associated with parents’ choice
between the two physicians.
DESIGN: Cross sectional study.
SETTING: Public, semi-private and private kindergartens in the city of Vila Nova de Famalicão
(Portugal).
PARTICIPANTS: Parents of children enrolled in the selected kindergartens, aged 6 years old or
less, without chronic diseases.
MAIN OUTCOME MEASURES: Proportion of children attending the FP or FP/Pediatrician for
their surveillance consultations. Association between the chosen Physician and
sociodemographic and household variables (parents´ age, educational level, professional
situation and marital status; household net income; number of children; child´s age; presence of
private health insurance). Assess the parents' perception of clinical knowledge and
accessibility, regarding the Family Physician and the Pediatrician.
RESULTS: A total of 697 children were included in the analysis: 30.6% attended only the FP
and 69.4% attended both the FP and the Pediatrician. Using a multivariable binary logistic
regression, the mother´s age (OR=1.06, 95% CI 1.01-1.12), higher educational level (OR=2.11,
95% CI 1.27–3.52), household net income higher than 2000 euros (OR=5.17, 95% CI 1.02–
26.17), private health insurance (OR=4.16, 95% CI 2.51–6.90), number of children (OR=0.56,
95% CI 0.40–0.78) and the child’s age (OR=0.98, 95% CI 0.97–0.99) were statistically
associated with attending both the FP and the Pediatrician. Parents of children who attended
only FP rated the FP with a higher accessibility and knowledge mean score than those who
consulted both physicians (2.91 versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001).
CONCLUSIONS: Our data shows that 70% of our sample simultaneously attended a FP and a
Pediatrician. Family Physicians are equally qualified to provide medical care to healthy children
but this information is not properly transmitted to the general population.
Keywords: Pediatric Assistant, Family Physician, Infant, Preschool Child, Primary
Health Care, Family Practice.
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Strengths and limitations of this study
- To our knowledge, this was the first study addressing the factors associated with par-
ents’ choice in the medical care of their children
- Our study has an adequate sampling, taking into consideration the three existing school
types: public, semi-private and private.
- We could only determine the variables associated with attending the FP or the Pediatri-
cian, but not the causes of this decision.
- We were able to confirm that there is in fact a substantial duplication of care in our
children surveillance.
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Introduction: According to the Robert Graham Center, in the United States, the ratio of children’s health care
provided by Family Physicians (FPs) decreased by about 33% between 1992 and 2002, from
one in four children to one in six.1,2 At the same time, there was an increase in the number of
visits provided by Pediatricians. FPs provide care to approximately 20% of the children between
birth and 5 years of age and increases to nearly 50% for adolescents, compared with 78% and
44%, respectively, in the case of the Pediatricians.1
FPs located in rural and underserved urban areas are more likely to provide care to children than
those in areas with higher pediatrician density.2,3 Children without health insurance or with
public health insurance are also more likely to be attended by FPs.1 Regarding the physician’s
characteristics, younger age and female sex are positively associated with medical care being
provided by FPs.3
Currently, the Portuguese health care system is characterized by two coexisting systems: the
public universal National Health Service (NHS) and the private sector. The latter includes
private insurance schemes for certain professions (health subsystems) and voluntary health
insurance. People can also have access to the private care without any insurance, paying the
total costs of the care provided. 4-5
The NHS is accessible to all residents in Portugal and provides primary and secondary health
care. It is financed mainly through taxation and tends to be free of charge, but co-payments can
be charged taking into account citizens’ social and economic conditions. However, there are
certain types of consultations free of charge regardless of individual income. This applies to all
children consultations in the NHS until the age of 18.5
The National Program for Child and Juvenile Health establishes 18 surveillance consultations
provided by Primary Care at specific ages, 13 of them on the first 6 years of life.6 Additionally,
there is a Portuguese National Vaccination Plan7, which is free of charge and only accessible
through the primary care of NHS.
Portuguese primary health care physicians have a four-year residency training which includes
Pediatrics rotation in secondary care and the normal surveillance of children included in the
Family Physician residency program8. This training enables FPs to surveille healthy children
and identify any disorders that can be either treated in primary care or that require referral to
Pediatrics in secondary care.
In the Portuguese NHS, Pediatricians work in secondary care and although they are also
qualified to follow healthy children, they mainly assume this role in the private sector.
There is no official data regarding the proportion of children followed simultaneously by FPs in
the NHS and by Pediatricians in private sector, but it is clear from daily practice that this choice
has been rising in the past years, which leads to duplicated care of healthy children.
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According to the national health survey of 2005/2006, 31,1% of children under fifteen are
followed by Pediatrician in private sector9. In 2016, in the city of Vila Nova de Famalicão, the
proportion of children with adequate surveillance by FPs in the first year of life was 80% and
79,3% in the second year of life.10
The use of multiple care providers is associated with poor continuity of care and excess costs to
the health care system. 11
Therefore, the main objectives of our study were to determine if children attend the FP or the
FP/Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the two physicians.
This takes particular importance since it was the first study to be done on this matter, as far as
we know.
METHODS:
Study design
This was a cross sectional study. In order to determine the factors associated with parents’
choices in the medical care of their children, a questionnaire was designed by the investigators
which is available in the supplementary annex, along with the protocol.
Ethical approval was obtained from the City Council of Vila Nova de Famalicão regarding the
public institutions and by the directors of the private and semi-private kindergartens, as required
by national legislation.
Setting and Study size
The study population comprised all children up to and including those with 6 years of age,
enrolled in public, semi-private and private kindergartens in the city of Vila Nova de Famalicão,
a county in the north of Portugal.
According to national statistics, in September of 2015, there were 4989 children enrolled in the
kindergartens in the city of Vila Nova de Famalicão.12-13 We determined a minimum sample size
of 536 valid questionnaires using OpenEpi, considering a 50% proportion of children being
attended simultaneously by FPs and Pediatricians, a confidence interval (CI) of 95% and a
design effect of 1.5. A conservative approach, using a 50% prevalence, was considered because
no evidence was available on the proportion of children simultaneously attended by FPs and
Pediatricians, at a national level. We considered that the number of delivered questionnaires
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should be three times greater in order to deal with non-delivered questionnaires and the
exclusion criteria, that could not be anticipated. At the time, this county had 89 kindergartens,
47 were public, 29 semi-private and 13 were private.14 We used a random sample that was
stratified by school type – public, semi-private, private. Strata weights were calculated using the
number of students in each specific stratum and the total number of students in all schools. In
each strata, schools were considered as sampling units and were randomly selected with
selection probabilities proportional to the number of students. In each stratum, school selection
process ended when the total number of children was superior to the determined sample size, for
each school type. For each school, all the parents were invited to participate.
Participants
Parents of children from the selected kindergartens were personally invited to participate and
the purpose of the study was explained to them by the teachers, who were previously trained by
the investigators. The parents who accepted to participate signed an informed consent and
received a questionnaire, delivered by the preschool teachers between April and May of 2016.
Surveys were preferably answered at home by both parents. Anonymity and confidentiality of
the data of all the participants, as they placed the unidentified questionnaires in a sealed box.
They were then collected by the investigators in June 2016.
We excluded the following children: those with chronic diseases followed by Pediatricians in
public hospitals; those up to 2 years old who had a Pediatrician but did not attend their services
in the last year, and those older than 2 years old that did not have a consultation in the last two
years. We also excluded children who did not have a FP and those who had a FP but did not
have adequate surveillance. Based on the National Program for Child and Juvenile Health6,
children are expected to attend nine surveillance consultations during the first two years of life,
and once a year until the age of 6. Consequently, we established inadequate surveillance as
attending less than 80% of the consultations for children up to 2 years old, and not attending the
FP in the last 2 years for older children in Primary Care. Surveys that were incomplete (under
80% of answered questions) were not considered for data analysis.
Variables and data collection instrument
The questionnaire consisted of two parts: the first comprised direct questions about the socio-
demographic characteristics related to parents, children and the household. The second part
consisted of statements about accessibility and knowledge, regarding the Family Physician and
the Pediatrician, to be rated according to a Likert scale. This scale includes five ordered re-
sponse levels varying between 1 and 5, measuring either negative, neutral or positive response
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to a statement. There were three questions about the clinical knowledge and four about the ac-
cessibility regarding each physician. To evaluate knowledge, parents were asked about their
perception for pediatric surveillance and acute/urgent disease management skills for both physi-
cians. Accessibility was assessed with questions about appointment scheduling (urgent, surveil-
lance and after working hours consultations), and the possibility to establish telephone contact
with the physicians.
Content validity was tested with eligible patients and minor modifications were implemented.
Data obtained by this process was not included in data analysis.
We included 13 sociodemographic and household variables in the analyses: parents’ age,
education level, professional situation and marital status; household size and net income;
number of children; child´s age and health insurance situation. Additionally, two more variables
were included, accessibility and clinical knowledge, related to the FP or Pediatrician.
Statistical methods
For statistical analysis, responders were divided in two groups: children that attended only the
Family Physician (FP group) and children that attended both the Family Physician and the
Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages, and continuous variables as
means and standard deviations.
Differences between FP and FP/Pediatrician groups’ characteristics were tested using Chi-
squared test for categorical variables and a Student’s t-test for independent samples.
Multivariable binary logistic regression model was used to test an association between
sociodemographic/household variables and FP or FP/Pediatrician group. This model included
as independent variables those that were clinically supported. The variables father´s age and
household size were not included as they are suspected to be highly correlated, contributing to
model multicollinearity. Model goodness-of-fit was accessed using Nagelkerke R2 and Hosmer
and Lemeshow test.
Perceptions of accessibility and knowledge were compared between FP and FP/Pediatrician
groups using independent t-tests. Additionally, accessibility and knowledge about the Family
Physician and Pediatrician were compared using a paired t-test, only for children who belonged
to the FP/Pediatrician group.
The sample was treated as a complex sample, considering the processes of stratification and
clustering, and using adequate weighting of cases for all statistic analysis.
Statistical analysis was performed with SPSS v23.0 and an α=0.05 was considered.
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RESULTS
A total of 697 questionnaires were considered for the analysis (Fig 1), 213 (30.6%) from the FP
group and 484 (69.4%) from the FP/Pediatrician group. The global missing data was 1,2% and
for each individual variable inferior to 3%.
Table 1 summarizes the sociodemographic and household characteristics of the participants
involved in the study. We found that the differences between the two groups for all the variables
were statistical significant, except for the father´s age. Higher education was more frequent in
the FP/Pediatrician group (42.3% versus 10.4% for the mother, p<0.001, and 24.9 % versus 5.4
% for the father, p<0.001). Active professional status was more frequent in FP/Pediatrician
group compared to the FP group (90% versus 78.3% for the mother, p<0.001, and 94.8% versus
86.8% for the father, p<0.001). Higher incomes were also more frequent in the Pediatrician/FP
group, with 71.3% having a monthly net income of 1000 euros (847£; 2245$) or more, com-
pared with only 36.3% in the FP group. Additionally, 45.1% of the children in the
PF/Pediatrician group and only 13.3% in the FP group had a private health insurance (p<0.001).
Table 1| Sociodemographic and household characteristics of the participants (n=697)
Total
n= 697
FP group
n= 213
FP/Pediatrici
an group
n= 484
p-
value
Mother’s age (years)
Mean ± SD
34.48 ± 5.73
33.48 ± 5.73
34.75 ± 4.46
<0.001
Mother’s education
Without higher education
With higher education
468 (67.4%) 226 (32.6%)
190 (89.6%) 22 (10.4%)
278 (57.7%) 204 (42.3%)
<0.001
Mother’s professional situa-
tion
Not active
Active
94 (13.5%) 600 (86.5%)
46 (21.7%)
166 (78.3%)
48(10.0%)
434 (90.0%) <0.001
Mother’s marital status
Single
Divorced/separated
Married/cohabiting couples
56 (8.1%)
31 (4.5%)
608 (87.5%)
27 (12.7%) 16 (7.5%)
170 (79.8%)
29 (6.0%)
15 (3.1%)
438 (90.9%)
<0.001
Father’s age (years)
Mean ± SD
36.27 ± 6.04
36.27 ± 6.04
36.84 ± 4.91
0.109
Father’s education
Without higher education
With higher education
556 (80.9%) 131 (19.1%)
194 (94.6%)
11 (5.4%)
362 (75.1%) 120 (24.9%)
<0.001
Father’s professional situation
Not active
Active
52 (7.6%)
634 (92.4%)
27 (13.2%)
177 (86.8%)
25 (5.2%)
457 (94.8%)
<0.001
Father’s marital status
Single
Divorced/separated
Married/ cohabiting couples
51 (7.4%) 35 (5.1%)
602 (87.5%)
23 (11.2%) 15 (7.3%)
167 (81.5%)
28 (5.8%) 20 (4.1%)
435 (90.1%)
<0.001
Household net income*
≤500€
501 to 999€
39 (5.8%)
225 (33.5%)
24 (11.8%)
106 (52.0%)
15 (3.2%)
119 (25.5%) <0.001
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*500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$;
†Number of people living in the same house. ‡Total number of children of both parents. SD: standard deviation; FP: Family Physician.
We adjusted a binary logistic regression (table 2) considering as dependent variable attending a
FP or attending FP/Pediatrician, and as independent variables all the ones presented on Table 1
except father´s age and household as they are suspected to be highly correlated, contributing to
model multicollinearity, and the parents´s marital state due to lack of clinical relevance.
Mother´s age and educational level, household net income higher than 2000 euros, private
health insurance, number of children and children´s age remained statistically associated with
attending both physicians, with an odds ratio (OR) of 1.06 for the mother´s age (95% CI 1.01-
1.12); 2.11 for the mother's educational level (95% CI 1.27 – 3.52); 5.17 (95% CI 1.02 – 26.17)
for household net income higher than 2000 euros when compared with a lower income (500€);
4.16 for having a private health insurance (95% CI 2.51 – 6.90); 0.56 for the number of children
(95% CI 0.40 – 0.78) and 0.98 for the child´s age in months (95% CI 0.97 – 0.99).
Table 2| Binary logistic regression for determination of variables associated with FP and FP/Pediatrician group.
Independent variables
OR
95% CI for OR
Mother´s age (years) 1.06 1.01-1.12
Mother’s education
Without higher education
With higher education
1
2.11
—
1.27 – 3.52
Mother’s professional situation
Not active
Active
1
1.90
—
0.98 – 3.70
Father’s education
Without higher education
With higher education
1
2.14
—
0.64 – 7.19
Father’s professional situation
Not active
Active
1
1.97
—
0.86 – 4.55
Household net income*
≤500€
501 to 999€ 1000 to 1999€
≥2000€
1 0.79 1.41 5.17
— 0.33 – 1.92 0.49 – 4.04
1.02 – 26.17
1000 to 1999€
≥2000€ 318 (47.4%) 89 (13.3%)
70 (34.3%) 4 (2.0%)
248 (53.1%) 85 (18.2%)
Private health insurance
No
Yes
449 (64.6%) 246 (35.4%)
184 (86.8%) 28 (13.2%)
265 (54.9%) 218 (45.1%)
<0.001
Household size†
Mean ± SD
3.79 ± 0.79
3.79 ± 0.79
3.56 ± 0.74
<0.001
Number of children‡
Mean ± SD
1.83 ± 0.77
1.83 ± 0.78
1.57 ± 0.66
<0.001
Child’s age (months)
Mean ± SD
51.41 ± 18.64
52.41± 18.67
45.44 ± 20.19
<0.001
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Private health insurance
No
Yes
1
4.16
—
2.51 – 6.90
Number of children‡ 0.56 0.40 – 0.78
Child’s age (months) 0.98 0.97 – 0.99
Hosmer and Lemeshow test p=0.704
R2 (Nagelkerke)
36%
ROC Curve AUROC = 0.81 (0.78 – 0.85), p<0.001 *500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; ‡Total number of children of both parents. ROC: Receiver Operating Characteristic. AUROC: Area Under the ROC Curve; OR: Odds Ratio. CI: Confidence interval. The FP group was considered as the reference group for the logistic regression. The variables father´s age and household size were not included as they are suspected to be highly correlated, contributing to model multicolline-arity. The parents’ marital status was not included due to lack of clinical relevance.
Regarding the parents’ perception about accessibility and clinical knowledge of the physicians,
we found statistical differences between the two groups (Table 3). The FP group rated the FP with
a higher accessibility and knowledge mean score comparing with FP/Pediatrician group (2.91
versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001). In the FP/Pediatrician group, the mean
score of accessibility and knowledge was significantly higher for the Pediatrician comparing
with the FP (4.29 versus 2.53, p<0.001, and 4.11 versus 3.85, p<0.001).
Table 3| Parents’ perception on accessibility and knowledge of the Family Physician and the Pediatrician.
Items about Knowledge related to
the: Items about Accessibility related to
the:
Family Physician Pediatrician Family Physician Pediatrician
Participants with Family Physician
4.11 ± 0.87* ------ (a)
2.91 ± 1.10* ------
(a)
Participants with Family Physician and Pediatrician
3.85 ± 0.87*
4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.77*
*mean ± standard deviation; (a) – did not have a Pediatrician
Discussion
In our study, only about 30% of the children attended exclusively the FP for surveillance con-
sultations, and 70% of the sample attended both the FP and the Pediatrician.
We found that the mother´s age and her educational level, household net income, private health
p<0.001 p<0.001 p<0.001 p<0.001
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insurance, number of children and the child’s age were associated with attending both the FP
and the Pediatrician. Variables with higher impact in the parents’ choice were household net
income higher than 2000 euros (OR =5.17, 95% CI 1.02 – 26.17), followed by having a private
health insurance (OR= 4.16, 95% CI 2.51 – 6.90). Both mother´s age and her educational level
were statistically associated with attending both physicians. However, father´s age and his edu-
cational level were not associated with the parents’ choice. This could be explained by social
and cultural influences in Portugal, where the mother is still recognized as the center of nurture
and care in the family life. Additionally, the number of children and the child´s age were also
associated with the parents’ choice. As the number of children increases within the household
and children grow older, there is an increasing odd of being followed only by the FP for surveil-
lance consultations. We think this may be explained by a higher experience and knowledge of
the parents about the child’s health. Furthermore, economic reasons may influence this choice
as the number of children grows. Our results are supported by the Robert Graham Center study1
findings: the proportion of children attending the Pediatrician decreases as the child grows older
and children with private health insurance are more likely to attend the Pediatrician. Regarding
parents’ perception of accessibility and clinical knowledge of the Family Physician and the Pe-
diatrician, we found statistical differences between the two groups. Parents who attended both
physicians rated the FP with lower accessibility and knowledge than those who consulted only
the FP.
Strengths and limitations
To our knowledge, there are no previous studies available regarding the factors associated with
parents’ choice in the medical care of their children, so this is the first one addressing this im-
portant subject. Other strengths of our study are an adequate sampling, taking into consideration
the three existing school types: public, semi-private and private.
The main limitation was that we could only determine the variables associated with attending
the FP or the Pediatrician, but not the causes of this decision because causality can not be evalu-
ated due to the study design.
Conclusions and implications for future research and practice
We identified variables associated with the parents’ choice in the medical care of their children,
with household net income and private health insurance being the most relevant ones.
Our data shows that Family Physicians still play an important role on children’s follow-up, even
though approximately 70% of our sample simultaneously attended a Pediatrician, which can
translate into a duplication of care and costs.
Unlike Pediatricians, the role of FPs is still unclear to most parents since they rated the FP with
a lower clinical knowledge mean than the Pediatrician. However, Family Physicians and Pedia-
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tricians are equally qualified to provide medical care to children without chronic diseases, with
the advantage that costs associated with the same surveillance consultations are lower when
carried out in Primary Health Care.15-18 Moreover, these facts should be advertised and included
in health care promotion and education that is provided to parents and the general population.
Additional investigation is relevant to understand if children’s medical care provided simulta-
neously by a Pediatrician and a FP is associated with health benefits and higher public health
costs when compared to medical care provided exclusively by the FP.
Footnotes
We thank the City Council of Vila Nova de Famalicão, the institutions that participated in the
study and all the parents who kindly answered the questionnaire.
Contributors: SR, SVR, JOL, AC, RT and JFM designed the study concept and design, wrote
the protocol and collected the data. All authors contributed to the questionnaire validation and
data collection. SR and FM conducted the analyses. All authors helped to draft the manuscript,
read and approved the final manuscript. All authors had full access to all data (including statisti-
cal reports and tables) in the study and can take responsibility for the integrity of the data and
the accuracy of the data analysis. SVR and JOL equally contributed to this article.
Carolina Gonçalves contributed to the study design. Lucélia Campinho, Susana Vilar Santos
and Vasco Duarte contributed to the questionnaire validation and data collection. SR and FM
are the study guarantors.
Funding: This study did not receive any external funding
Competing interests: None declared.
Contributorship Statement: All authors completed the ICMJE uniform disclosure form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
Ethical approval: Ethical approval was obtained from the City Council of Vila Nova de Fama-
licão, in the context of the program Aproximar, as required by national legislation.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the manu-
script is an honest, accurate, and transparent account of the study being reported; that no im-
portant aspects of the study have been omitted; and that any discrepancies from the study as
planned have been registered.
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Data sharing: questionnaire available on request to the corresponding author.
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References
1. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS,
Weitzman M, Green L. Report to the Task Force on the Care of Children by Family Physicians. Washington, DC. The Robert Graham Center for Policy Studies in Family Medicine and Primary Care in collaboration with the American Academy of Pediatrics Center for Child Health Research; 2005.
2. Bazemore AW, Makaroff LA, Puffer JC, Parhat P, Phillips RL, Xirali IM, Rinaldo J. Declining Numbers of Family Physicians are Caring for Children. Journal of the American Board of Family Medicine 2012; 25 (2): 139-140.
3. Makaroff LA, Xierali IM, Petterson SM, Shipman SA, Puffer JC, Bazemore AW. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce 2014; 12 (5): 427-431.
4. Jakubowski E, Busse R. Health Care Systems in the EU: a comparative study. European Parliament. Luxemburg, 1998.
5. Barros P, Machado S, Simões J. Portugal: Health system review. Health Sys-tems in Transition, 2011, 13(4):1–156.
6. Direção Geral de Saúde. Programa Nacional de Saúde Infantil e Juvenil. Portugal, Lisbon. Direção Geral de Saúde 2013; 10/2013: 9-11
7. Direção Geral de Saúde. Programa Nacional de Vacinação 2017. Portugal, Lisbon. Direção Geral de Saúde 2017; 16/2016.
8. Ministério da Saúde. Diário da República, 1.ª série, N.º 36 — 20 de fevereiro de 2015
9. Entidade Reguladora da Saúde. Caracterização do Acesso dos Utentes a Cuidados de Saúde Infantil e Juvenil e de Pediatria. Março 2011
10. SIARS platform. P01.02.02.R01. Relatório de Indicadores ACeS no Período em análise (accessed on 3 july 2017).
11. Macpherson A,Kramer M, Ducharme F, Yang H, Bélanger F. Doctor shopping before and after a visit to a paediatric emergency department. Paediatr Child Health. 2001 Jul-Aug; 6(6): 341–346.
12. Gabinete de Estratégia e Planeamento. Carta Social. Resposta Social: Creche – Equipamentos existentes no Distrito de Braga, Concelho de Vila Nova de Famalicão. Available on: http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false (accessed on 5 September 2015).
13. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. Posrtugal, Lisbon 2015; 197-200.
14. Câmara Municipal de Vila Nova de Famalicão. Jardins-de-infância. Available on: http://www.cm-vnfamalicao.pt/_jardins_de_infancia_2 (accessed on 5 September 2015).
15. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 2005; 83(3): 457–502.
16. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. The Journal of Family Practice 1998; 47(2):105-9.
17. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. Medicare costs in urban areas and the supply of primary care physicians. The Journal of Family Practice 1996; 43(1):33-9.
18. Doescher MP, Franks P, Saver BG. Is family care associated with reduced health
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care expenditures? he Journal of Family Practice 1999; 48(8):608-14. Figure Legends:
Fig 1| Flowchart showing the sample selection.
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Fig 1| Flowchart showing the sample selection.
210x297mm (300 x 300 DPI)
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STROBE Statement
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
– Page 2 (Design: cross sectional study)
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found – Page 2
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported –
Page 4 (Introduction – First, second and third paragraphs)
Objectives 3 State specific objectives, including any prespecified hypotheses – Page 4
(Introduction – Fourth paragraph)
Methods
Study design 4 Present key elements of study design early in the paper – Page 4 (Methods: study
design)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection – Page 5 (Setting and study design – first
and second paragraphs; Participants – first paragraph)
Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants – Page 5 (Setting and study design –first and second
paragraph) and Page 6 (first paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable – Page 6 (Statistical methods –
first paragraph)
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there is
more than one group – Page 4 (Methods: study design), Page 6 (Variables).
Bias 9 Describe any efforts to address potential sources of bias
Information bias – Page 5 (Participants – first paragraph)
Selection bias – Page 5 (Setting and study design –second paragraph)
Study size 10 Explain how the study size was arrived at – Page 5 (Setting and study design –
second paragraph)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why – Page 6 (Statistical methods)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding -
Page 6 (Statistical methods)
(b) Describe any methods used to examine subgroups and interactions - Page 6
(Statistical methods – third paragraph)
(c) Explain how missing data were addressed - Page 6 (firts paragraph) and Page 7
(Results –first paragraph)
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy - Page 5 (Setting and study design –second paragraph)
(e) Describe any sensitivity analyses – not applicable
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed - Page 7 (Figure 1)
(b) Give reasons for non-participation at each stage - Page 7 (Figure 1)
(c) Consider use of a flow diagram - Page 7 (Figure 1)
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders – Page 8 (table 1) and Results – second paragraph
(b) Indicate number of participants with missing data for each variable of interest – Page 7
(Results –first paragraph).
Cross-sectional study—Report numbers of outcome events or summary measures - Page 7-8:
results
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included - Page 9 (first paragraph and table 2)
(b) Report category boundaries when continuous variables were categorized –Page 8 (table 1)
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period - not applicable
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses - not applicable
Discussion
Key results 18 Summarise key results with reference to study objectives – Page 10 (Discussion – first and
second paragraphs)
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias – Page 11 (Strengths and
limitations)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence – Page 10 (Discussion –
second paragraph) and Page 11 (Conclusions and implications for future research and
practice)
Generalisability 21 Discuss the generalisability (external validity) of the study results - Page 11 (Conclusions and
implications for future research and practice)
Other information
Funding 22 No funding – page 12
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua , Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino-Machado.
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Authors:
1- Susana Rebelo (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 2- Sofia Velho Rua (Family Medicine Resident in Family Health Unit Ribeirão) 3- Joana d’Orey Leça (Family Medicine Resident in Family Health Unit Terras do Ave) 4- Ana Faria Couto (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 5- Rute Teixeira (Family Physician in Family Health Unit S. Miguel-o-Anjo) 6- Joõa Firmino-Machado (Public Health Resident in WesternOportoPublicHealthUnit)
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Index
LIST of ABBREVIATIONS.........................................................................................................................................4
ABSTRACT........................................................................................................................................................................5
INTRODUCTION.............................................................................................................................................................6
OBJECTIVES.....................................................................................................................................................................7
POPULATION...................................................................................................................................................................7
SAMPLE..............................................................................................................................................................................7
Sampling technique..................................................................................................................................7Sample size...............................................................................................................................................8
PARTICIPANTS...............................................................................................................................................................8
VARIABLES....................................................................................................................................................................10
METHODS........................................................................................................................................................................12
Study location.........................................................................................................................................12Type, duration and study period.............................................................................................................12Study design...........................................................................................................................................12Pilot study..............................................................................................................................................12
COLLABORATOR’S TRAINING...........................................................................................................................13
STATISTICAL ANALYSIS.......................................................................................................................................13
STUDY TIMELINE:......................................................................................................................................................14
MANAGEMENT AND BUDGET............................................................................................................................15
AUTHORS........................................................................................................................................................................15
REFERENCES.................................................................................................................................................................15
APPENDIX I: QUESTIONNAIRE...........................................................................................................................17
APPENDIX II: INFORMED CONSENT...............................................................................................................23
Informed Consent Form for Study Participation....................................................................................23
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LIST OF ABBREVIATIONS
ACeS – Agrupamento de Centros de Saúde
FP – Family Physician
OR – Odds Ratio
PHC - Primary Health Care
USF – Unidade de Saúde Familiar
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua, Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino Machado.
ABSTRACT
Introduction: In the United States, the ratio of children’s health care provided by Family
Physicians (FPs) decreased by about 33% between 1992 and 2002, from one in four children to
one in six, and, at the same time, there was a significant growth in the number of visits provided
by Pediatricians.
Objectives: To determine if children attend the FP or the Pediatrician for their surveillance
consultations, as well as the variables associated with the parents’ choice between the FP and the
Pediatrician.
Methods and Analysis: Cross sectional analytical study, with an expected duration of one year
and two months. The study population will comprise all parents of pre-school children enrolled
in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate
in the study. The kindergartens will be randomly selected until a statistically significant sample
is obtained. The authors will contact each institution and assess the interest in participating in the
study. Between April and May 2016 all parents of the selected institutions will be invited to
participate in the study. They will have to sign an informed consent and receive a questionnaire
that was created by the investigators and that will be validated by a previous pilot study. The filled
questionnaires will be placed in a sealed box and the investigators will collect them in June 2016.
Statistical analysis will be performed with SPSS v23.0.
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INTRODUCTION
Primary Health Care (PHC) is ideally the first point of contact that a patient has with the
health care system. It has a key role in care providing as it assumes a longitudinal continuity of
care, from birth till death, and a holistic approach of the patient, taking into account his familiar,
social, economic, professional, cultural and many other aspects that comprise his context.
The Family Physician attends patients from both sexes, all age groups, ethnicities, races
and socio-economic levels. However, the age group that includes children from 0 to 18 years
assumes particular importance in PHC. It is a priority group that justifies a bigger effort and
willingness by health providers.
In the United States, the ratio of children’s health care provided by Family Physicians
(FPs) decreased by about 33% between 1992 and 2002, from one in four children to one in six (1;
2) and, at the same time, there was a significant growth in the number of visits provided by
Pediatricians. FPs provide care to approximately 16% of the children between birth and 5 years
of age, compared with 73% in the case of the Pediatricians (1).
FPs located in rural and underserved urban areas are more likely to provide care to
children than those in areas with higher pediatrician density (2; 3). Children without private health
insurance or with public health insurance are also more likely to be attended by FPs (1). Regarding
the physician’s characteristics, younger age and female sex are positive predictors for medical
care being provided by FPs (3).
In Portugal, from 1992 to 2015 the number of Pediatricians and FPs(4) more than doubled
and the birth rate declined from 11,5 to 8,3 live births per 1000 persons (5). The National Program
for Child and Juvenile Health (6) establishes 18 surveillance consultations at specific ages, 13 of
them on the first 6 years of life. These consultations are intended to be done in the Primary Health
Care system but, even though there are no official numbers, it is clear that the number of children
who are simultaneously attended by a Pediatrician in private care is rising.
Therefore, the main objectives of our study are to determine if children attend the FP or
the Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the FP and the Pediatrician. This takes particular importance since it is
the first study to be done on this matter.
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OBJECTIVES
1. To determine the variables related to the parents’ choice of the physician (Family
Physician or Pediatrician) for the surveillance consultations of their children.
2. To determine if there is an association between the choice of the physician and the
following variables:
• Parents´ age
• Parents´ educational level
• Parents´ professional situation
• Parents´ marital status
• Household net income
• Household size
• Number of children
• Child’s age
• Presence of private health insurance
3. To assess the parents' perception of the scientific and clinical knowledge, as well as the
accessibility to the physician (FP or Pediatrician).
POPULATION Vila Nova de Famalicão is a town and municipality in the district of Braga, in the north
of Portugal. It has an area of 201.8 km² (7), distributed between 34 civil parishes (8). In 2011, the
population was 133,832 (9).
According to national statistics, in September of 2015, there were 4989 children enrolled
in the kindergartens in the municipality of Vila Nova de Famalicão. This population was
calculated using the data published in Carta Social (10) and the document “Regiões em Números
2013/2014, Volume I-Norte” (11), of the Direção Geral de Estatísticas e da Educação e Ciências.
According to those documents, there were about 1517 children attending kindergartens (10) (up to 3 years old) and approximately 3472 children in pre-school education (3-6 years) (11).
SAMPLE Sampling technique
According to the City Council of Vila Nova de Famalicão (12), there were 89 kindergartens
and pre-school in the county, of which 13 were private, 29 semi-private and 47 public.
We randomized a sample that was stratified by school type – public, semi-public, private. In each
strata, schools were considered as sampling units and were randomly selected with selection
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probabilities proportional to the number of students. For each school, all the parents were invited
to participate.
Sample size
We determined a minimum sample size of 536 valid questionnaires using OpenEpi, using a
prevalence of 50%, a confidence interval (CI) of 95% and a design effect of 1.5. At the time, this
county had 89 kindergartens, 13 were private, 29 semi-private and 47 public (12). We considered
that the number of delivered questionnaires should be three times greater in order to deal with
non-delivered questionnaires and the exclusion criteria, that could not be anticipated. We used a
random sample that was stratified by school type – public, semi-public, private. Strata weights
were calculating the number of students in each specific stratum and the total number of students
in all schools. In each strata, schools were considered as sampling units and were randomly
selected with selection probabilities proportional to the number of students. In each stratum school
selection process ended when the total number of children was superior to the determined sample
size, for each school type. For each school, all the parents were invited to participate.
PARTICIPANTS The study participants will comprise all parents, of the selected kindergartens, with children up
to and including those with 6 years old.
Inclusion criteria
• Parents of children up to and including those with 6 years old, enrolled in public, semi-
private and private kindergartens in the city of Vila Nova de Famalicão
• Parents who agree to take part in the study.
Exclusion criteria
• Children with chronic diseases followed by Pediatricians.
• Children in public hospital following.
• Children up to 2 years old who had a Pediatrician but did not attend their services in the
last year.
• Children older than 2 years old who had a Pediatrician but did not attend their services in
the last two years.
• Children who did not have a FP.
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• Children with a FP but did not had adequate surveillance
• Surveys with more than 20% of unanswered questions
Based on The National Program for Child and Juvenile Health (6), we defined inadequate
surveillance as attending less than 80% of the consultations for children up to 2 years old and not
attending the FP in the last 2 years for older children.
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VARIABLES
The study variables, their operational definition, the type and the values that the variable can take are described in detail in Table 1.
Table 1 – Operational definition, type, acceptable values and coding of the variables under study.
Variable Definition Variable type Values that the variable can take
Child´s physician Physician responsible for the surveillance consultations Categorical
nominal
FP group
FP/Pediatrician group
Mother´s age Number of years between the date of birth and the date of data collection Continuous
Mother´s educational
level
Mother’s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Mother’s professional
situation
Employment situation of mother at the time of data collection Categorical
nominal
Not active
Active
Mother´s marital
status
Mother´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Father´s age Number of years between the date of birth and the date of data collection Continuous
Father´s educational
level
Father´s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Father’s professional
situation
Employment situation of father at the time of data collection Categorical
nominal
Not active
Active
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Father´s marital
status
Father´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Household net income
Monthly net income of the household, in euros. Categorical
Ordinal
≤500€
501 to 999€
1000 to 1999€
≥2000€
Private health
insurance
Private health insurance that includes the child or child with his own private
health insurance
Categorical Yes
No
Household size Number of people living in the same house. Continuous
Number of children Total number of children of the mother and the father Continuous
Child´s age (months) Number of months between the date of birth and the date of data collection Continuous
FP’s knowledge Parents’ perception about the scientific and clinical knowledge of the FP. Categorical
Ordinal
1-5
Pediatrician’s
knowledge
Parents’ perception about the scientific and clinical knowledge of the
Pediatrician.
Categorical
Ordinal
1-5
FP’s accessibility Parents’ perception about the accessibility to the FP. Categorical
Ordinal
1-5
Pediatrician’s
accessibility
Parents’ perception about the accessibility to the Pediatrician. Categorical
Ordinal
1-5
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METHODS
Study location
Selected kindergartens and pre-schools institutions in Vila Nova de Famalicão.
Type, duration and study period
Cross sectional analytical study, with an expected duration of one year and five months
(from June 2015 to November 2016).
Study design
Parents of children enrolled in the selected kindergartens will be invited to participate and
the purpose of the study will be explained to them by the teachers, who will be previously trained
by the investigators. The parents who accept to participate will sign an informed consent and
receive a questionnaire, which will be delivered by the preschool teachers between April and May
of 2016. Surveys must be answered at home by both parents, if possible. It will be guaranteed the
anonymity and confidentiality of the data of all the participants, as they will place the unidentified
questionnaires in a sealed box. The sealed boxes will be collected by the investigators in June
2016.
In order to determine the factors associated with parents’ choices in the medical care of
their children, a questionnaire was created by the investigators (Appendix I). This consists of two
parts: the first comprises direct questions about the sociodemographic characteristics related to
parents, children and the household. The second part consists of statements about accessibility
and knowledge, regarding the Family Physician and the Pediatrician, to be rated according to a
Likert scale. This scale includes five ordered response levels varying between 1 and 5. A pilot
study will be conducted in the eligible population to test content validity.
Pilot study
A pilot study will be conducted in the eligible population to test content validity. The pilot
study will be conducted in February 2016 and it will consist on applying the questionnaire in the
eligible population followed by an interview, in a small sample (approximately 30 persons). In
the interview, it will be discussed with the participants, topics as the time necessary for the
questionnaire, the question’s format and pertinence, and all the comments that they feel
appropriate, and if necessary, changes will be made in the questionnaire to its final version.
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COLLABORATOR’S TRAINING
It will take place in a multidisciplinary meeting in every institution that accepts to
participate in the study and it will consist on presenting to the teachers the study objectives,
duration and timeline, population and the inclusion and exclusion criteria, and clarification of any
question that might occur. In every meeting, there will be at least two members of the
investigation team present.
The teachers that accept to participate will be asked to sign a declaration of commitment.
STATISTICAL ANALYSIS For statistical analysis, the sample will be divided in two groups: children that attended
only the Family Physician (FP group) and children that attended both the Family Physician and
the Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages and continuous
variables as means and standard deviations. Shapiro-Wilk test will be used to test for normality.
Differences between FP and FP/Pediatrician groups’ characteristics will be tested using qui-
square test or independent sample T-test, as appropriate. Multivariate binary logistic regression
model will be used to determine the variables associated with FP or FP/Pediatrician group. This
model will include as independent variables only those identified by univariate analysis, with p-
values <0,1.
Perceptions of accessibility and knowledge will be compared between FP and
FP/Pediatrician groups using independent T-tests. Additionally, accessibility and knowledge
about the Family Physician and Pediatrician will be compared using a paired sample T-test, only
for children who belong to the FP/Pediatrician group.
Statistical analysis will be performed with SPSS v23.0 and p<0,05 will be defined as
statistically significant.
:
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STUDY TIMELINE:
The data collection process will be held according to the following steps:
Table 1 – Study timeline
2015 2016
June - December January February March April May June July August September November
Protocol and questionnaire design
Submission to ethical approval
Contact with the director of the selected kindergartens and pre-schools
Collaborators’ training
Pilot study
Questionnaires delivery
Data analysis and results discussion
Release of the results
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MANAGEMENT AND BUDGET
The study authors are responsible for the protocol design, collaborators’ training, data
analysis and release of the results. Table 2 shows the required material and budget to the
implementation of the study. All costs of the study will be supported by the authors.
Table 2 – Study material and budget.
Material Unitary Cost (€) x Number of unites required
Cost (€)
Informed consent 0.03 x 4 x 1400 168
Questionnaires (A4) 0.03 x 6 x 1400 252
Travel expenses 200 200
Other expenses 300 300
Total cost - 920
AUTHORS
Susana Rebelo (Family Health Unit S. Miguel-o-Anjo) Ana Faria Couto (Family Health Unit S. Miguel-o-Anjo) Joana d’Orey Leça (Family Health Unit Terras do Ave) Sofia Velho Rua (Family Health Unit Ribeirão) Rute Teixeira (Family Health Unit S. Miguel-o-Anjo) Firmino Machado (Western Oporto Public Health Unit)
REFERENCES
1. Report to the Task Force on the Care of Children by Family Physicians. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS, Weitzman M, Green L. s.l. : The Robert Graham Center: Policy Studies in Family Medicine and Primary Care In collaboration with the American Academy of Pediatrics Center for Child Health Research, 2005.
2. Declining Numbers of Family Physicians are Caring for Children. Bazemore A, Makaroff L, Puffer J, Parhat P, Phillips R, Xirali I, Rinaldo J. 2012, Journal of the American Board of Family Medicine, Vols. 25, No 2, pp. 139-140.
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3. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce. Makaroff LA, Xierali IM, Petterson S, Shipman S, Puffer J, Bazemore A. 2014, Annals of Family Medicine, Vols. 12, No 5.
4. PORDATA: Base de Dados Portugal Contemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Médicos+não+especialistas+e+especialistas+por+especialidade-147.
5. PORDATA: Dados de Portugal Comtemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Taxa+bruta+de+natalidade-527.
6. Programa Nacional de Saúde Infantil e Juvenil. Direção Geral de Saúde. s.l. : Lisboa : Direção Geral de Saúde. , 2013. , Vol. Vol. nº 10/2013.
7. Camara Municipal: Vila Nova de Famalicão. Carta Educativa do Municipio de Vila Nova de Famalicão. Vila Nova de Famalicão : s.n., 2009.
8. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 05 de September de 2015.] http://www.cm-vnfamalicao.pt/_freguesias_7.
9. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_censos_2011__populacao.
10. Gabinete de Estratégia e Planeamento. Carta Social. [Online] [Citação: 5 de September de 2015.] http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false..
11. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015 : s.n.
12. Famalicão, Camara Municipal: Vila Nova de. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_jardins_de_infancia_.
13. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015.
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APPENDIX I: QUESTIONNAIRE
We would like to invite you to participate in a research study designed five Family
Physicians that work in three different health institutions in the county of Vila Nova de Famalicão
(Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-
o-Anjo) and a Public Health Physician. To that effect, your participation would consist of filling
out the questionnaire in the appendix. Its purpose is to know the factors that determine parents’
choice of the physician (Family Physician or Pediatrician) for their children’s surveillance
consultations.
It will be guaranteed the anonymity and confidentiality of the data of all the participants
and they will be used exclusively for the purpose of this study.
The authors thank you for your collaboration.
Ana Faria Couto | Family Medicine Resident in Family Health Unit Familiar S. Miguel-o-Anjo
João Firmino Machado | Public Health Resident in WesternOportoPublicHealthUnit
Joana d’Orey Leça | Family Medicine Resident in Family Health Unit Terras do Ave
Rute Teixeira | Family Physician in Family Health Unit S. Miguel-o-Anjo
Sofia Velho Rua | Family Medicine Resident in Family Health Unit Ribeirão
Susana Rebelo | Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo
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1. Age (type the number): ___________ years
2. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widow
3. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
4. Professional situation
Active
Unemployed
Retired
Student
5. Age (type the number): ___________ years
6. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widower
MOTHER'SIDENTIFICATION
FATHER'SIDENTIFICATION
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1. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
2. Professional situation
Active Unemployed
Retired
Student
Household
3. Number of household members (number of people living in your home): ___________________________
4. How many children do you have? (please take into consideration the mother and the father’s children)____________________________
5. Average monthly household income (after tax)
499 euros or less
from 500 to 999 euros
from 1000 euros to 1999 euros
2000 euros or more
6. Does your child have a private health insurance of his own? Do you have a private
health insurance that includes your child?
Yes No
7. Date of birth of your child (DD/MM/YYYY)
_____/______/__________
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8. Does your child have any chronic disease1?
Yes No I don’t know
9. Does your child have an assigned Family Physician?
Yes No
a. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
10. Does your child have a Pediatrician?
Yes No
a. If so, where?
Public Hospital Private Hospital/ Clinic b. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
1Chronic disease: disease with more than 6 months of duration, which implies more frequent medical follow-up, beyond the surveillance consultations defined in the health record of your child.
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The following questions aim to know your opinion about your Family Physician’s skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
The Family Physician is empowered to conduct surveillance consultations of my son.
The Family Physician has expertise to solve acute/urgent diseases of my son.
It is easy to schedule an appointment with the Family Physician.
It is easy to schedule an appointment on the same day in case of an acute/urgent disease with the Family Physician.
It is easy to talk by telephone with the Family Physician in case of illness.
It is easy to schedule an appointment after working hours in the Family Physician.
Surveillance by the Family Physician is important because of the knowledge that he has about the family context.
Quiz
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The following questions aim to know your opinion about the Pediatrician's skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
I think that the Pediatrician has more knowledge and clinical practice related to children than the Family Physician.
I believe that my son is best followed by a Pediatrician, regardless of the Family Physician’s quality.
I believe that children should always be followed by a Pediatrician, even if simultaneously followed by the Family Physician.
It is easy to schedule an appointment with the Pediatrician.
It is easy to schedule an appointment on the same day with the Pediatrician in case of an acute/urgent disease.
It is easy to talk by telephone with the Pediatrician in case of illness.
It is easy to schedule an appointment after working hours with the Pediatrician.
Thank you for your collaboration!
CompleteonlyifyourchildisfollowedbyaPediatricianinaprivatehospitalorclinic.
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Author’ssignatures_______________________________________________________________________________________________________________________
APPENDIX II: INFORMED CONSENT
Informed Consent Form for Study Participation
according to Declaration of Helsinki2 and Oviedo Convention3
You have been invited to participate in a research study, please read carefully all the information below. If you believe that there is an incorrect or unclear information, do not hesitate to ask for clarification. If you agree to participate, please sign this document.
Title of study: “Are healthy children attended by the family physician or the pediatrician? Determinants of an important decision”
Purpose of the Study: This is a research study designed by five Family Physicians that work in three different health institutions in the county of Vila Nova de Famalicão 8Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-o-Anjo) and a Public Health Physician. The main objective is to know the factors that determine parents’ choice of the physician (Family Physician or Pediatrician) for their children’s surveillance consultations. The study population will comprise parents of pre-school children enrolled in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate in the study. To that effect, your participation will consist of filling out an anonymous questionnaire that will be given to you by the children’s teachers.
Conditions and compensations: There will be no compensations nor prejudice for the participants. The parents’ collaboration is voluntary and, therefore, you are free to refuse to participate. Ethical approval was obtained from the City Council of Vila Nova de Famalicão, in the context of the program Aproximar, as required by national legislation.
Confidentiality and anonymity: It is guaranteed the anonymity and confidentiality of the data of all the participants and they will be used exclusively for the purpose of this study. It was requested and granted authorization of National Data Protection Commission.
The authors thank you for your collaboration.
Susana Rebelo | Family Health Unit S. Miguel-o-Anjo |[email protected] Ana F. Couto | Family Health Unit S. Miguel-o-Anjo | [email protected] João Firmino Machado | Western Oporto Public Health Unit | [email protected] Joana d’Orey Leça | Family Health Unit Terras do Ave | [email protected] Rute Teixeira | Family Health Unit S. Miguel-o-Anjo | [email protected] Sofia Velho Rua | Family Health Unit Ribeirão | [email protected]
-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o- Your signature below indicates that you have read the document and that you confirm all the following:
1. The study has been explained to you and all of your questions have been answered. 2. You understand why the study is being conducted and how it will be performed. 3. You understand that your participation is voluntary and that you can refuse to participate at any
point of the study without any kind of prejudice.
2http://portal.arsnorte.min-saude.pt/portal/page/portal/ARSNorte/Comiss%C3%A3o%20de%20%C3%89tica/Ficheiros/Declaracao_Helsinquia_2008.pdf
3http://dre.pt/pdf1sdip/2001/01/002A00/00140036.pdf
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4. You understand that anonymity and confidentiality will be guaranteed and that all data will be used exclusively for the purpose of the study.
5. You understand your rights and you voluntarily consent to your child’s participation in this study. 6. You have been told you will receive a copy of this form.
Name: … … … … … … … …... … … … …... … … … … … … … … … … … … Signature: … … … … … … … …... … … … … ... … … … … … … … … … … … … Date: …… /…… /………..
THIS IS A 2 PAGE AND DUPLICATED DOCUMENT: ONE COPY FOR THE INVESTIGATOR
AND ONE FOR THE PARTICIPANT
If illiterate: I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Print name of witness: … … … … … …… … … … … … … … Thumb print of participant Signature of witness: … … … … … …… … … … … …… … Date …… /…… /………..
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Is healthy children surveillance being duplicated by Family
Physicians and Paediatricians? A cross-sectional study in
Portugal.
Journal: BMJ Open
Manuscript ID bmjopen-2017-015902.R3
Article Type: Research
Date Submitted by the Author: 14-Nov-2017
Complete List of Authors: Rebelo, Susana; Family Health Unit S. Miguel-o-Anjo Velho Rua, Sofia; Family Health Unit Ribeirão d´Orey Leça, Joana ; Family Health Unit Terras do Ave Couto, Ana; Family Health Unit S. Miguel-o-Anjo Teixeira, Rute; Family Health Unit Serzedelo Firmino-Machado, João; EPIUnit; Unidade de Saúde Pública ACeS Porto Ocidental
<b>Primary Subject Heading</b>:
General practice / Family practice
Secondary Subject Heading: Paediatrics
Keywords: Paediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice
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Is healthy children surveillance being duplicated by Family Physicians
and Paediatricians? A cross-sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João Firmino-Machado6
Sofia Velho Rua and Joana d’Orey Leça equally contributed to this article.
1 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Susana Rebelo Family Medicine Res-ident.
2 Family Health Unit Ribeirão, Northern Regional Health Administration, Rua da Extensão de Saúde, 4760-715 Ribeirão, Portugal, Sofia Velho Rua Family Medicine Resident.
3 Family Health Unit Terras do Ave, Northern Regional Health Administration, Rua do Pavilhão, 4765-628 Delães, Portugal, Joana d’Orey Leça Family Medicine Resident.
4 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine Assistant.
5 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Rute Teixeira Family Physician Assistant.
6 Western Oporto Public Health Unit, Northern Regional Health Administration, Rua de Vila Nova 503, 4100 Porto; EPI Unit, Rua das Taipas, 4050-600 Porto, Portugal, João Firmino Machado Public Health Resident.
Corresponding to: S Rebelo [email protected]
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Abstract
OBJECTIVES: To determine if children attend the Family Physician (FP) or the
FP/Paediatrician for their surveillance medical appointments, as well as analyse the variables
associated with the parents’ choice between the two physicians.
DESIGN: Cross-sectional study.
SETTING: Public, semi-private and private kindergartens in the city of Vila Nova de Famalicão
(Portugal).
PARTICIPANTS: Parents of children enrolled in the selected kindergartens, aged 6 years old or
less, without chronic diseases.
MAIN OUTCOME MEASURES: Proportion of children attending the FP or FP/Paediatrician
for their surveillance appointments; association between the chosen Physician and
sociodemographic and household variables (parents´ age, educational level, professional
situation and marital status; household net income; number of children; child´s age; presence of
private health insurance); assess the parents' perception of clinical knowledge and accessibility,
regarding the Family Physician and the Paediatrician.
RESULTS: A total of 697 children were included in the analysis: 30.6% attended only the FP
and 69.4% attended both the FP and the Paediatrician. Using a multivariable-binary logistic
regression, the mother´s age (OR=1.06, 95% CI 1.01-1.12), higher educational level (OR=2.11,
95% CI 1.27–3.52), household net income higher than 2,000 euros (OR=5.17, 95% CI 1.02–
26.17), private health insurance (OR=4.16, 95% CI 2.51–6.90), number of children (OR=0.56,
95% CI 0.40–0.78) and the child’s age (OR=0.98, 95% CI 0.97–0.99) were statistically
associated with attending both the FP and the Paediatrician; parents of children who attended
only FP rated the FP with a higher accessibility and knowledge mean score than those who
consulted both physicians (2.91 versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001).
CONCLUSIONS: Our data shows that 70% of our sample simultaneously attended an FP and a
Paediatrician. Family Physicians are equally qualified to provide medical care to healthy
children but this information is not properly transmitted to the general population.
Keywords: Paediatric Assistant, Family Physician, Infant, Preschool Child, Primary
Health Care, Family Practice.
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Strengths and limitations of this study
- To our knowledge, this was the first study addressing the factors associated with parents’
choice in the medical care of their children;
- Our study has an adequate sampling, taking into consideration the three existing school
types: public, semi-private and private;
- We could only determine the variables associated with attending the FP or the Paediatri-
cian, but not the causes of this decision;
- We were able to confirm that there is in fact a substantial duplication of care in our chil-
dren surveillance.
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Introduction:
According to the Robert Graham Center in the United States, the ratio of children’s health care
provided by Family Physicians (FPs) decreased by about 33% between 1992 and 2002, from
one in four children to one in six.1,2 At the same time, there was an increase in the number of
visits provided by Paediatricians. FPs provide care to approximately 20% of the children
between birth and 5 years of age, and increases to nearly 50% for adolescents, compared with
78% and 44%, respectively, in the case of the Paediatricians.1
FPs located in rural and underserved urban areas are more likely to provide care to children than
those in areas with a higher density of paediatricians.2,3 Children who do not have health
insurance or public health insurance are also more likely to be attended by FPs.1 Regarding the
physician’s characteristics, younger age and female sex are positively associated with medical
care being provided by FPs.3
Currently, the Portuguese health care system is characterised by two coexisting systems: the
public universal National Health Service (NHS) and the private sector. The latter includes
private insurance schemes for certain professions (health subsystems) and voluntary health
insurance. People can also have access to the private care without any insurance, paying the
total costs of the care provided. 4-5
The NHS is accessible to all residents in Portugal and provides primary and secondary health
care. It is financed mainly through taxation and tends to be free of charge, but co-payments can
be charged taking into account citizens’ social and economic conditions. However, there are
certain types of appointments free of charge, regardless of individual income. This applies to all
children medical appointments in the NHS until the age of 18.5
The National Programme for Child and Juvenile Health establishes 18 surveillance
appointments provided by Primary Care at specific ages, 13 of them on the first 6 years of life.6
Additionally, there is a Portuguese National Vaccination Plan7, which is free of charge and only
accessible through the primary care of NHS.
Portuguese primary health care physicians have a four-year residency training which includes
Paediatrics rotation in secondary care and the normal surveillance of children included in the
Family Physician residency program8. This training enables FPs to monitor healthy children and
identify any disorders that can be either treated in primary care or that require referral to
Paediatrics in secondary care.
In the Portuguese NHS, Paediatricians work in secondary care, and although they are also
qualified to follow healthy children, they mainly assume this role in the private sector.
There is no official data regarding the proportion of children followed simultaneously by FPs in
the NHS and by Paediatricians in the private sector, but it is clear from daily practice that this
choice has been increasing in the past years, leading to duplicated care of healthy children.
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According to the national health survey of 2005/2006, 31,1% of children under fifteen are
followed by Paediatricians in the private sector9. In 2016, in the county of Vila Nova de
Famalicão, the proportion of children with adequate surveillance by FPs in the first year of life
was 80% and 79,3% in the second year of life.10
The use of multiple care providers is associated with poor continuity of care and excess costs to
the health care system.11 According to the behavioural model developed by Andersen the use of
health services is determined by three dynamics: predisposing factors, enabling factors and
need.12-13 Some studies have shown that parents with higher education level, higher incomes and
engaging in employment are considered predisposing factors to seek appropriate healthcare
services for their children.14-18
Therefore, the main objectives of our study consisted both in determining whether children
attend the FP or the FP/Paediatrician in their surveillance appointments, and in ascertaining the
variables associated with the parents’ choice between the two physicians.
This study takes particular importance since, to the best of our knowledge, it was the first study
to be accomplished on this matter.
METHODS:
Study design Since this was a cross-sectional study, in order to determine the factors associated with parental
choices in the medical care of their children, a questionnaire was designed by the researchers.
And it has been enclosed in the supplementary annex, along with the protocol.
Ethical approval was obtained from the City Council of Vila Nova de Famalicão, regarding
public institutions and by the directors of the private and semi-private kindergartens, as required
by national legislation.
Setting and Study size
The study population comprised all children up to 6 years of age, including those, enrolled in
public, semi-private and private kindergartens in the city of Vila Nova de Famalicão, a county
in the north of Portugal.
According to national statistics, in September 2015 there were 4989 children enrolled in the
kindergartens in the city of Vila Nova de Famalicão.19-20 We determined a minimum sample size
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of 536 valid questionnaires using OpenEpi, considering a 50% proportion of children being
attended simultaneously by FPs and Paediatricians, a confidence interval (CI) of 95% and a
design effect of 1.5. A conservative approach, using a 50% prevalence, was considered because
no evidence was available on the proportion of children simultaneously attended by FPs and
Paediatricians, at a national level. We considered that the number of delivered questionnaires
should be three times greater in order to deal with non-delivered questionnaires and the
exclusion criteria which could not be anticipated. At the time, this county comprised 89
kindergartens, 47 of which were public, 29 semi-private and 13 were private.21 We used a
random sample that was stratified by school type – public, semi-private, private. Strata weights
were calculated using the number of students in each specific stratum and the total number of
students in all schools. In each stratum, schools were considered as sampling units and were
randomly chosen with selection probabilities proportional to the number of students. And again,
in each stratum, the school selection process ended when the total number of children was
superior to the determined sample size for each school type. Therefore, all the parents from the
selected schools were invited to participate.
Participants
The parents of children from the selected kindergartens were personally invited to participate
and the purpose of the study was explained to them by the teachers who were previously trained
by the researchers. The parents who accepted to participate signed an informed consent and
received a questionnaire delivered by the preschool teachers between April and May 2016.
Surveys were preferably answered at home by both parents. Anonymity and confidentiality of
all the participants’ data was maintained, as they placed the unidentified questionnaires in a
sealed box. They were then collected by the researchers in June 2016.
We excluded the following children: those with chronic diseases followed by Paediatricians in
public hospitals; those up to 2 years of age who had a Paediatrician, but did not attend their
services in the previous year; and those older than 2 years old who had not had an
appointment in the two preceding years . We also excluded children who did not have an FP and
those who had an FP but did not have adequate monitoring. Based on the National Programme
for Child and Juvenile Health6, children are expected to attend nine surveillance appointments
during the first two years of life, and once a year until the age of 6. Consequently, we
established as inadequate surveillance attending less than 80% of the appointments for children
up to 2 years old, and not having attended the FP in the 2 previous years for older children in
Primary Care. Incomplete surveys (under 80% of answered questions) were not considered for
data analysis.
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Variables and data collection instrument
The questionnaire consisted of two parts: the first comprised direct questions about the socio-
demographic characteristics related to parents, children and the household. The second part
consisted of statements about accessibility and knowledge regarding the Family Physician and
the Paediatrician, to be rated according to a Likert scale. This scale includes five ordered re-
sponse levels varying between 1 and 5, measuring either negative, neutral or positive response
to a statement. There were three questions about the clinical knowledge and four about the ac-
cessibility regarding each physician. To evaluate knowledge, parents were asked about their
perception for paediatric surveillance and acute/urgent disease management skills for both phy-
sicians. Accessibility was assessed with questions about appointment scheduling (urgent, moni-
toring and after work hours appointments), and the possibility to establish telephone contact
with the physicians.
Content validity was tested with eligible patients and minor modifications were implemented.
Data obtained by this process was not included in data analysis.
We included 13 socio-demographic and household variables in the analyses: parents’ age,
education level, professional situation and marital status; household size and net income;
number of children; child´s age and health insurance situation. Additionally, two more
variables, accessibility and clinical knowledge, related to the FP or Paediatrician, were included,
Statistical methods
For statistical analysis, responders were divided in two groups: children that attended only the
Family Physician (FP group) and children that attended both the Family Physician and the
Paediatrician (FP/Paediatrician group).
Categorical variables are described as frequencies and percentages, and continuous variables as
means and standard deviations.
Differences between FP and FP/Paediatrician groups’ characteristics were tested using Chi-
squared test for categorical variables and a Student’s t-test for independent samples. The
Multivariable binary logistic regression model was used to test an association between socio-
demographic/household variables and FP or FP/Paediatrician groups. This model included as
independent variables, those that were clinically supported. The variables father´s age and
household size were not included as they are suspected to be highly correlated, contributing to
model multi-collinearity. Model goodness-of-fit was accessed using Nagelkerke R2 and Hosmer
and Lemeshow test.
Perceptions of accessibility and knowledge were compared between FP and FP/Paediatrician
groups using independent t-tests. Additionally, accessibility and knowledge about the Family
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Physician and Paediatrician were compared using a paired t-test, only for children who
belonged to the FP/Paediatrician group.
The sample was treated as complex, considering the processes of stratification and clustering,
and using adequate weighting of cases for all statistical analysis.
The latter was performed with SPSS v23.0 and an α=0.05 was taken into account.
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RESULTS
A total of 697 questionnaires were considered for the analysis (Fig 1), 213 (30.6%) from the FP
group and 484 (69.4%) from the FP/Paediatrician group. The global missing data was 1,2% and
for each individual variable it was inferior to 3%.
Table 1 summarizes the socio-demographic and household characteristics of the participants
involved in the study. We found that the differences between the two groups for all the variables
were statistically significant, except for the father´s age. Higher education was more frequent in
the FP/Paediatrician group (42.3% versus 10.4% for the mother, p<0.001, and 24.9 % versus 5.4
% for the father, p<0.001). The active professional status was more frequent in the
FP/Paediatrician group when compared to the FP group (90% versus 78.3% for the mother,
p<0.001, and 94.8% versus 86.8% for the father, p<0.001). Higher incomes were also more
frequent in the Paediatrician/FP group, with 71.3% having a monthly net income of 1000 euros
(847£; 2245$) or more, compared with only 36.3% in the FP group. Additionally, 45.1% of the
children in the PF/Paediatrician group and only 13.3% in the FP group had private health insur-
ance (p<0.001).
Table 1| Socio-demographic and household characteristics of the participants (n=697)
Total
n= 697
FP group
n= 213
FP/Paediatri
cian group
n= 484
p-
value
Mother’s age (years)
Mean ± SD
34.48 ± 5.73
33.48 ± 5.73
34.75 ± 4.46
<0.001
Mother’s education
Without higher education
With higher education
468 (67.4%) 226 (32.6%)
190 (89.6%) 22 (10.4%)
278 (57.7%) 204 (42.3%)
<0.001
Mother’s professional situa-
tion
Not active
Active
94 (13.5%) 600 (86.5%)
46 (21.7%)
166 (78.3%)
48(10.0%)
434 (90.0%) <0.001
Mother’s marital status
Single
Divorced/separated
Married/cohabiting couples
56 (8.1%)
31 (4.5%)
608 (87.5%)
27 (12.7%) 16 (7.5%)
170 (79.8%)
29 (6.0%)
15 (3.1%)
438 (90.9%)
<0.001
Father’s age (years)
Mean ± SD
36.27 ± 6.04
36.27 ± 6.04
36.84 ± 4.91
0.109
Father’s education
Without higher education
With higher education
556 (80.9%) 131 (19.1%)
194 (94.6%)
11 (5.4%)
362 (75.1%) 120 (24.9%)
<0.001
Father’s professional situation
Not active
Active
52 (7.6%)
634 (92.4%)
27 (13.2%)
177 (86.8%)
25 (5.2%)
457 (94.8%) <0.001
Father’s marital status
Single
Divorced/separated
Married/ cohabiting couples
51 (7.4%) 35 (5.1%)
602 (87.5%)
23 (11.2%) 15 (7.3%)
167 (81.5%)
28 (5.8%) 20 (4.1%)
435 (90.1%)
<0.001
Household net income*
≤500€
39 (5.8%)
24 (11.8%)
15 (3.2%)
<0.001
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*500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; †Number of people living in the same house. ‡Total number of children of both parents. SD: standard deviation; FP: Family Physician.
We adjusted a binary logistic regression (table 2) considering as dependent variable attending a
FP or attending a FP/Paediatrician, and as independent variables all the ones presented on Table 1.
We excluded the father´s age and household size as they were suspected to be highly correlated,
and the parents´ marital state due to lack of clinical relevance. Variables such as mother´s
educational level and age, household net income higher than 2000 euros, private health
insurance, number of children and children´s age remained statistically associated with
attending both physicians, with an odds ratio (OR) of 1.06 for the mother´s age (95% CI 1.01-
1.12); 2.11 for the mother's educational level (95% CI 1.27 – 3.52); 5.17 (95% CI 1.02 – 26.17)
for household net income higher than 2000 euros when compared with a lower income (500€);
4.16 for having a private health insurance (95% CI 2.51 – 6.90); 0.56 for the number of children
(95% CI 0.40 – 0.78) and 0.98 for the child´s age in months (95% CI 0.97 – 0.99). There was no
significant association between the father´s educational level or the parents’ professional
situation and the outcome. The presented model fits adequately to data and is accurately
predicting the outcome (accessed by Hosmer and Lemeshow test and R2Nagelkerke) allowing
valid interpretation of the model parameters.
Table 2| Binary logistic regression for determination of variables associated with FP and FP/Paediatrician group.
Independent variables
OR
95% CI for OR
Mother´s age (years) 1.06 1.01-1.12
Mother’s education
Without higher education
With higher education
1
2.11
—
1.27 – 3.52 Mother’s professional situation
Not active
Active
1
1.90
—
0.98 – 3.70 Father’s education
Without higher education
With higher education
1
2.14
—
0.64 – 7.19 Father’s professional situation
Not active
Active
1
1.97
—
0.86 – 4.55
501 to 999€ 1000 to 1999€
≥2000€
225 (33.5%) 318 (47.4%) 89 (13.3%)
106 (52.0%) 70 (34.3%) 4 (2.0%)
119 (25.5%) 248 (53.1%) 85 (18.2%)
Private health insurance
No
Yes
449 (64.6%) 246 (35.4%)
184 (86.8%) 28 (13.2%)
265 (54.9%) 218 (45.1%)
<0.001
Household size†
Mean ± SD
3.64 ± 0.78
3.79 ± 0.79
3.56 ± 0.74
<0.001
Number of children‡
Mean ± SD
1.83 ± 0.77
1.83 ± 0.78
1.57 ± 0.66
<0.001
Child’s age (months)
Mean ± SD
51.41 ± 18.64
52.41± 18.67
45.44 ± 20.19
<0.001
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Household net income*
≤500€
501 to 999€ 1000 to 1999€
≥2000€
1 0.79 1.41 5.17
— 0.33 – 1.92 0.49 – 4.04
1.02 – 26.17 Private health insurance
No
Yes
1
4.16
—
2.51 – 6.90 Number of children‡ 0.56 0.40 – 0.78 Child’s age (months) 0.98 0.97 – 0.99
Hosmer and Lemeshow test p=0.704 R
2 (Nagelkerke)
36% ROC Curve AUROC = 0.81 (0.78 – 0.85), p<0.001 *500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; ‡Total number of children of both parents. ROC: Receiver Operating Characteristic. AUROC: Area Under the ROC Curve; OR: Odds Ratio. CI: Confidence interval. The FP group was considered as the reference group for the logistic regression. The variables father´s age and household size were not included as they are suspected to be highly correlated, contributing to model multi-collinearity. The parents’ marital status was not included due to lack of clinical relevance.
Regarding the parents’ perception about accessibility and clinical knowledge of the physicians,
we found statistical differences between the two groups (table 3). The FP group rated the FP
with a higher accessibility and knowledge mean score comparing with FP/Paediatrician group
(2.91 versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001). In the FP/Paediatrician group, the
mean score of accessibility and knowledge was significantly higher for the Paediatrician
comparing with the FP (4.29 versus 2.53, p<0.001, and 4.11 versus 3.85, p<0.001).
Table 2| Parents’ perception on accessibility and knowledge of the Family Physician and the Paediatrician.
Items about Knowledge related to
the: Items about Accessibility related to
the:
Family Physician Paediatrician Family Physician Paediatrician
Participants with Family Physician
4.11 ± 0.87* ------ (a)
2.91 ± 1.10* ------
(a)
Participants with Family Physician and Paediatrician
3.85 ± 0.87*
4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.77*
*mean ± standard deviation; (a) – did not have a Paediatrician
p<0.001 p<0.001 p<0.001 p<0.001
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Discussion
In our study, only about 30% of the children attended exclusively the FP for surveillance ap-
pointments, and 70% of the sample attended both the FP and the Paediatrician.
We found that the mother´s age and her educational level, household net income, private health
insurance, number of children and the child’s age were associated with attending both the FP
and the Paediatrician. Variables with higher impact in the parents’ choice were household net
income higher than 2000 euros (OR =5.17, 95% CI 1.02 – 26.17), followed by having a private
health insurance (OR= 4.16, 95% CI 2.51 – 6.90). Both mother´s age and her educational level
were statistically associated with attending both physicians. However, father´s age and his edu-
cational level were not associated with the parents’ choice. This could be explained by social
and cultural influences in Portugal where the mother is still considered as the centre of nurture
and care in the family life. Additionally, both the number of children and the child´s age were
also associated with the parents’ choice. As the number of children increases within the house-
hold, and as children grow older, there is an increasing odd of being followed only by the FP for
surveillance appointments. We think this may be explained by a higher experience and parent’s
awareness about the child’s health. Furthermore, economic reasons may influence this choice as
the number of children grows. Our results are supported by the Robert Graham Center study1
findings: the proportion of children attending the Paediatrician decreases as the child grows
older and children with private health insurance are more likely to attend the Paediatrician. Re-
garding the parents’ perception of accessibility and the clinical knowledge of the Family Physi-
cian and the Paediatrician, we found statistical differences between the two groups. Parents who
attended both physicians rated the FP with lower accessibility and knowledge than those who
consulted only the FP.
Strengths and limitations
To the best of our knowledge, there are no previous studies available regarding the factors asso-
ciated with parents’ choice in the medical care of their children, so this is the first one address-
ing this important subject. Other strengths of our study are an adequate sampling, taking into
consideration the three existing school types: public, semi-private and private.
The main limitation found by the researchers was that only the variables associated with attend-
ing the FP or the Paediatrician were determined. The causes of this decision could not be deter-
mined as causality cannot be evaluated with this study design.
Conclusions and implications for future research and practice
We identified variables associated with the parents’ choice in the medical care of their children,
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with household net income and private health insurance being the most relevant ones.
Our data shows that Family Physicians still play an important role on children’s follow-up, even
though approximately 70% of our sample simultaneously attended a Paediatrician. This can
translate into a duplication of care and costs.
Unlike Paediatricians, the role of FPs is still unclear to most parents since they rated the FP with
a lower clinical knowledge mean than the Paediatrician. Nonetheless, Family Physicians and
Paediatricians are equally qualified to provide medical care to children without chronic diseases,
with the advantage that costs associated with the same surveillance appointments are lower
when carried out in Primary Health Care.22-25 Moreover, these facts should be advertised and
included in health care promotion and education that is provided to parents and the general pop-
ulation.
Additional investigation is relevant to understand if children’s medical care provided simulta-
neously by a Paediatrician and an FP is associated with health benefits and higher public health
costs when compared to medical care provided exclusively by the FP.
Footnotes
We would like to thank the City Council of Vila Nova de Famalicão, and acknowledge the con-
tribution of the institutions that participated in the study and also the willingness of all the par-
ents who kindly answered the questionnaire.
Contributors: SR, SVR, JOL, AC, RT and JFM designed the study concept and design, wrote
the protocol and collected the data. All authors contributed to the questionnaire validation and
data collection. SR and FM conducted the analyses. All authors helped to draft the manuscript,
read and approved the final manuscript. All authors had full access to all data (including statisti-
cal reports and tables) in the study and can take responsibility for the integrity of the data and
the accuracy of the data analysis. SVR and JOL equally contributed to this article.
Carolina Gonçalves contributed to the study design. Lucélia Campinho, Susana Vilar Santos
and Vasco Duarte contributed both to questionnaire validation and data collection. SR and FM
are the study guarantors.
Funding: This study did not receive any external funding
Competing interests: None declared.
Contributorship Statement: All authors completed the ICMJE uniform disclosure form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
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Ethical approval: Ethical approval was obtained from the City Council of Vila Nova de Fama-
licão, in the context of the programme “Aproximar”, as required by national legislation.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the manu-
script is an honest, accurate, and transparent account of the study being reported; that no im-
portant aspects of the study have been omitted; and that any discrepancies from the study as
planned have been registered.
Data sharing: questionnaire available on request to the corresponding author.
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References
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Figure Legends:
Fig 1| Flowchart showing the sample selection.
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Fig 1| Flowchart showing the sample selection.
210x297mm (300 x 300 DPI)
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STROBE Statement
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
– Page 2 (Design: cross sectional study)
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found – Page 2
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported –
Page 4 (Introduction – First, second and third paragraphs)
Objectives 3 State specific objectives, including any prespecified hypotheses – Page 4
(Introduction – Fourth paragraph)
Methods
Study design 4 Present key elements of study design early in the paper – Page 4 (Methods: study
design)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection – Page 5 (Setting and study design – first
and second paragraphs; Participants – first paragraph)
Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants – Page 5 (Setting and study design –first and second
paragraph) and Page 6 (first paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable – Page 6 (Statistical methods –
first paragraph)
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there is
more than one group – Page 4 (Methods: study design), Page 6 (Variables).
Bias 9 Describe any efforts to address potential sources of bias
Information bias – Page 5 (Participants – first paragraph)
Selection bias – Page 5 (Setting and study design –second paragraph)
Study size 10 Explain how the study size was arrived at – Page 5 (Setting and study design –
second paragraph)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why – Page 6 (Statistical methods)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding -
Page 6 (Statistical methods)
(b) Describe any methods used to examine subgroups and interactions - Page 6
(Statistical methods – third paragraph)
(c) Explain how missing data were addressed - Page 6 (firts paragraph) and Page 7
(Results –first paragraph)
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy - Page 5 (Setting and study design –second paragraph)
(e) Describe any sensitivity analyses – not applicable
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed - Page 7 (Figure 1)
(b) Give reasons for non-participation at each stage - Page 7 (Figure 1)
(c) Consider use of a flow diagram - Page 7 (Figure 1)
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders – Page 8 (table 1) and Results – second paragraph
(b) Indicate number of participants with missing data for each variable of interest – Page 7
(Results –first paragraph).
Cross-sectional study—Report numbers of outcome events or summary measures - Page 7-8:
results
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included - Page 9 (first paragraph and table 2)
(b) Report category boundaries when continuous variables were categorized –Page 8 (table 1)
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period - not applicable
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses - not applicable
Discussion
Key results 18 Summarise key results with reference to study objectives – Page 10 (Discussion – first and
second paragraphs)
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias – Page 11 (Strengths and
limitations)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence – Page 10 (Discussion –
second paragraph) and Page 11 (Conclusions and implications for future research and
practice)
Generalisability 21 Discuss the generalisability (external validity) of the study results - Page 11 (Conclusions and
implications for future research and practice)
Other information
Funding 22 No funding – page 12
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua , Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino-Machado.
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Authors:
1- Susana Rebelo (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 2- Sofia Velho Rua (Family Medicine Resident in Family Health Unit Ribeirão) 3- Joana d’Orey Leça (Family Medicine Resident in Family Health Unit Terras do Ave) 4- Ana Faria Couto (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 5- Rute Teixeira (Family Physician in Family Health Unit S. Miguel-o-Anjo) 6- Joõa Firmino-Machado (Public Health Resident in WesternOportoPublicHealthUnit)
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Index
LIST of ABBREVIATIONS.........................................................................................................................................4
ABSTRACT........................................................................................................................................................................5
INTRODUCTION.............................................................................................................................................................6
OBJECTIVES.....................................................................................................................................................................7
POPULATION...................................................................................................................................................................7
SAMPLE..............................................................................................................................................................................7
Sampling technique..................................................................................................................................7Sample size...............................................................................................................................................8
PARTICIPANTS...............................................................................................................................................................8
VARIABLES....................................................................................................................................................................10
METHODS........................................................................................................................................................................12
Study location.........................................................................................................................................12Type, duration and study period.............................................................................................................12Study design...........................................................................................................................................12Pilot study..............................................................................................................................................12
COLLABORATOR’S TRAINING...........................................................................................................................13
STATISTICAL ANALYSIS.......................................................................................................................................13
STUDY TIMELINE:......................................................................................................................................................14
MANAGEMENT AND BUDGET............................................................................................................................15
AUTHORS........................................................................................................................................................................15
REFERENCES.................................................................................................................................................................15
APPENDIX I: QUESTIONNAIRE...........................................................................................................................17
APPENDIX II: INFORMED CONSENT...............................................................................................................23
Informed Consent Form for Study Participation....................................................................................23
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LIST OF ABBREVIATIONS
ACeS – Agrupamento de Centros de Saúde
FP – Family Physician
OR – Odds Ratio
PHC - Primary Health Care
USF – Unidade de Saúde Familiar
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua, Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino Machado.
ABSTRACT
Introduction: In the United States, the ratio of children’s health care provided by Family
Physicians (FPs) decreased by about 33% between 1992 and 2002, from one in four children to
one in six, and, at the same time, there was a significant growth in the number of visits provided
by Pediatricians.
Objectives: To determine if children attend the FP or the Pediatrician for their surveillance
consultations, as well as the variables associated with the parents’ choice between the FP and the
Pediatrician.
Methods and Analysis: Cross sectional analytical study, with an expected duration of one year
and two months. The study population will comprise all parents of pre-school children enrolled
in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate
in the study. The kindergartens will be randomly selected until a statistically significant sample
is obtained. The authors will contact each institution and assess the interest in participating in the
study. Between April and May 2016 all parents of the selected institutions will be invited to
participate in the study. They will have to sign an informed consent and receive a questionnaire
that was created by the investigators and that will be validated by a previous pilot study. The filled
questionnaires will be placed in a sealed box and the investigators will collect them in June 2016.
Statistical analysis will be performed with SPSS v23.0.
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INTRODUCTION
Primary Health Care (PHC) is ideally the first point of contact that a patient has with the
health care system. It has a key role in care providing as it assumes a longitudinal continuity of
care, from birth till death, and a holistic approach of the patient, taking into account his familiar,
social, economic, professional, cultural and many other aspects that comprise his context.
The Family Physician attends patients from both sexes, all age groups, ethnicities, races
and socio-economic levels. However, the age group that includes children from 0 to 18 years
assumes particular importance in PHC. It is a priority group that justifies a bigger effort and
willingness by health providers.
In the United States, the ratio of children’s health care provided by Family Physicians
(FPs) decreased by about 33% between 1992 and 2002, from one in four children to one in six (1;
2) and, at the same time, there was a significant growth in the number of visits provided by
Pediatricians. FPs provide care to approximately 16% of the children between birth and 5 years
of age, compared with 73% in the case of the Pediatricians (1).
FPs located in rural and underserved urban areas are more likely to provide care to
children than those in areas with higher pediatrician density (2; 3). Children without private health
insurance or with public health insurance are also more likely to be attended by FPs (1). Regarding
the physician’s characteristics, younger age and female sex are positive predictors for medical
care being provided by FPs (3).
In Portugal, from 1992 to 2015 the number of Pediatricians and FPs(4) more than doubled
and the birth rate declined from 11,5 to 8,3 live births per 1000 persons (5). The National Program
for Child and Juvenile Health (6) establishes 18 surveillance consultations at specific ages, 13 of
them on the first 6 years of life. These consultations are intended to be done in the Primary Health
Care system but, even though there are no official numbers, it is clear that the number of children
who are simultaneously attended by a Pediatrician in private care is rising.
Therefore, the main objectives of our study are to determine if children attend the FP or
the Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the FP and the Pediatrician. This takes particular importance since it is
the first study to be done on this matter.
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OBJECTIVES
1. To determine the variables related to the parents’ choice of the physician (Family
Physician or Pediatrician) for the surveillance consultations of their children.
2. To determine if there is an association between the choice of the physician and the
following variables:
• Parents´ age
• Parents´ educational level
• Parents´ professional situation
• Parents´ marital status
• Household net income
• Household size
• Number of children
• Child’s age
• Presence of private health insurance
3. To assess the parents' perception of the scientific and clinical knowledge, as well as the
accessibility to the physician (FP or Pediatrician).
POPULATION Vila Nova de Famalicão is a town and municipality in the district of Braga, in the north
of Portugal. It has an area of 201.8 km² (7), distributed between 34 civil parishes (8). In 2011, the
population was 133,832 (9).
According to national statistics, in September of 2015, there were 4989 children enrolled
in the kindergartens in the municipality of Vila Nova de Famalicão. This population was
calculated using the data published in Carta Social (10) and the document “Regiões em Números
2013/2014, Volume I-Norte” (11), of the Direção Geral de Estatísticas e da Educação e Ciências.
According to those documents, there were about 1517 children attending kindergartens (10) (up to 3 years old) and approximately 3472 children in pre-school education (3-6 years) (11).
SAMPLE Sampling technique
According to the City Council of Vila Nova de Famalicão (12), there were 89 kindergartens
and pre-school in the county, of which 13 were private, 29 semi-private and 47 public.
We randomized a sample that was stratified by school type – public, semi-public, private. In each
strata, schools were considered as sampling units and were randomly selected with selection
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probabilities proportional to the number of students. For each school, all the parents were invited
to participate.
Sample size
We determined a minimum sample size of 536 valid questionnaires using OpenEpi, using a
prevalence of 50%, a confidence interval (CI) of 95% and a design effect of 1.5. At the time, this
county had 89 kindergartens, 13 were private, 29 semi-private and 47 public (12). We considered
that the number of delivered questionnaires should be three times greater in order to deal with
non-delivered questionnaires and the exclusion criteria, that could not be anticipated. We used a
random sample that was stratified by school type – public, semi-public, private. Strata weights
were calculating the number of students in each specific stratum and the total number of students
in all schools. In each strata, schools were considered as sampling units and were randomly
selected with selection probabilities proportional to the number of students. In each stratum school
selection process ended when the total number of children was superior to the determined sample
size, for each school type. For each school, all the parents were invited to participate.
PARTICIPANTS The study participants will comprise all parents, of the selected kindergartens, with children up
to and including those with 6 years old.
Inclusion criteria
• Parents of children up to and including those with 6 years old, enrolled in public, semi-
private and private kindergartens in the city of Vila Nova de Famalicão
• Parents who agree to take part in the study.
Exclusion criteria
• Children with chronic diseases followed by Pediatricians.
• Children in public hospital following.
• Children up to 2 years old who had a Pediatrician but did not attend their services in the
last year.
• Children older than 2 years old who had a Pediatrician but did not attend their services in
the last two years.
• Children who did not have a FP.
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• Children with a FP but did not had adequate surveillance
• Surveys with more than 20% of unanswered questions
Based on The National Program for Child and Juvenile Health (6), we defined inadequate
surveillance as attending less than 80% of the consultations for children up to 2 years old and not
attending the FP in the last 2 years for older children.
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VARIABLES
The study variables, their operational definition, the type and the values that the variable can take are described in detail in Table 1.
Table 1 – Operational definition, type, acceptable values and coding of the variables under study.
Variable Definition Variable type Values that the variable can take
Child´s physician Physician responsible for the surveillance consultations Categorical
nominal
FP group
FP/Pediatrician group
Mother´s age Number of years between the date of birth and the date of data collection Continuous
Mother´s educational
level
Mother’s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Mother’s professional
situation
Employment situation of mother at the time of data collection Categorical
nominal
Not active
Active
Mother´s marital
status
Mother´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Father´s age Number of years between the date of birth and the date of data collection Continuous
Father´s educational
level
Father´s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Father’s professional
situation
Employment situation of father at the time of data collection Categorical
nominal
Not active
Active
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Father´s marital
status
Father´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Household net income
Monthly net income of the household, in euros. Categorical
Ordinal
≤500€
501 to 999€
1000 to 1999€
≥2000€
Private health
insurance
Private health insurance that includes the child or child with his own private
health insurance
Categorical Yes
No
Household size Number of people living in the same house. Continuous
Number of children Total number of children of the mother and the father Continuous
Child´s age (months) Number of months between the date of birth and the date of data collection Continuous
FP’s knowledge Parents’ perception about the scientific and clinical knowledge of the FP. Categorical
Ordinal
1-5
Pediatrician’s
knowledge
Parents’ perception about the scientific and clinical knowledge of the
Pediatrician.
Categorical
Ordinal
1-5
FP’s accessibility Parents’ perception about the accessibility to the FP. Categorical
Ordinal
1-5
Pediatrician’s
accessibility
Parents’ perception about the accessibility to the Pediatrician. Categorical
Ordinal
1-5
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METHODS
Study location
Selected kindergartens and pre-schools institutions in Vila Nova de Famalicão.
Type, duration and study period
Cross sectional analytical study, with an expected duration of one year and five months
(from June 2015 to November 2016).
Study design
Parents of children enrolled in the selected kindergartens will be invited to participate and
the purpose of the study will be explained to them by the teachers, who will be previously trained
by the investigators. The parents who accept to participate will sign an informed consent and
receive a questionnaire, which will be delivered by the preschool teachers between April and May
of 2016. Surveys must be answered at home by both parents, if possible. It will be guaranteed the
anonymity and confidentiality of the data of all the participants, as they will place the unidentified
questionnaires in a sealed box. The sealed boxes will be collected by the investigators in June
2016.
In order to determine the factors associated with parents’ choices in the medical care of
their children, a questionnaire was created by the investigators (Appendix I). This consists of two
parts: the first comprises direct questions about the sociodemographic characteristics related to
parents, children and the household. The second part consists of statements about accessibility
and knowledge, regarding the Family Physician and the Pediatrician, to be rated according to a
Likert scale. This scale includes five ordered response levels varying between 1 and 5. A pilot
study will be conducted in the eligible population to test content validity.
Pilot study
A pilot study will be conducted in the eligible population to test content validity. The pilot
study will be conducted in February 2016 and it will consist on applying the questionnaire in the
eligible population followed by an interview, in a small sample (approximately 30 persons). In
the interview, it will be discussed with the participants, topics as the time necessary for the
questionnaire, the question’s format and pertinence, and all the comments that they feel
appropriate, and if necessary, changes will be made in the questionnaire to its final version.
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COLLABORATOR’S TRAINING
It will take place in a multidisciplinary meeting in every institution that accepts to
participate in the study and it will consist on presenting to the teachers the study objectives,
duration and timeline, population and the inclusion and exclusion criteria, and clarification of any
question that might occur. In every meeting, there will be at least two members of the
investigation team present.
The teachers that accept to participate will be asked to sign a declaration of commitment.
STATISTICAL ANALYSIS For statistical analysis, the sample will be divided in two groups: children that attended
only the Family Physician (FP group) and children that attended both the Family Physician and
the Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages and continuous
variables as means and standard deviations. Shapiro-Wilk test will be used to test for normality.
Differences between FP and FP/Pediatrician groups’ characteristics will be tested using qui-
square test or independent sample T-test, as appropriate. Multivariate binary logistic regression
model will be used to determine the variables associated with FP or FP/Pediatrician group. This
model will include as independent variables only those identified by univariate analysis, with p-
values <0,1.
Perceptions of accessibility and knowledge will be compared between FP and
FP/Pediatrician groups using independent T-tests. Additionally, accessibility and knowledge
about the Family Physician and Pediatrician will be compared using a paired sample T-test, only
for children who belong to the FP/Pediatrician group.
Statistical analysis will be performed with SPSS v23.0 and p<0,05 will be defined as
statistically significant.
:
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STUDY TIMELINE:
The data collection process will be held according to the following steps:
Table 1 – Study timeline
2015 2016
June - December January February March April May June July August September November
Protocol and questionnaire design
Submission to ethical approval
Contact with the director of the selected kindergartens and pre-schools
Collaborators’ training
Pilot study
Questionnaires delivery
Data analysis and results discussion
Release of the results
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MANAGEMENT AND BUDGET
The study authors are responsible for the protocol design, collaborators’ training, data
analysis and release of the results. Table 2 shows the required material and budget to the
implementation of the study. All costs of the study will be supported by the authors.
Table 2 – Study material and budget.
Material Unitary Cost (€) x Number of unites required
Cost (€)
Informed consent 0.03 x 4 x 1400 168
Questionnaires (A4) 0.03 x 6 x 1400 252
Travel expenses 200 200
Other expenses 300 300
Total cost - 920
AUTHORS
Susana Rebelo (Family Health Unit S. Miguel-o-Anjo) Ana Faria Couto (Family Health Unit S. Miguel-o-Anjo) Joana d’Orey Leça (Family Health Unit Terras do Ave) Sofia Velho Rua (Family Health Unit Ribeirão) Rute Teixeira (Family Health Unit S. Miguel-o-Anjo) Firmino Machado (Western Oporto Public Health Unit)
REFERENCES
1. Report to the Task Force on the Care of Children by Family Physicians. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS, Weitzman M, Green L. s.l. : The Robert Graham Center: Policy Studies in Family Medicine and Primary Care In collaboration with the American Academy of Pediatrics Center for Child Health Research, 2005.
2. Declining Numbers of Family Physicians are Caring for Children. Bazemore A, Makaroff L, Puffer J, Parhat P, Phillips R, Xirali I, Rinaldo J. 2012, Journal of the American Board of Family Medicine, Vols. 25, No 2, pp. 139-140.
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3. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce. Makaroff LA, Xierali IM, Petterson S, Shipman S, Puffer J, Bazemore A. 2014, Annals of Family Medicine, Vols. 12, No 5.
4. PORDATA: Base de Dados Portugal Contemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Médicos+não+especialistas+e+especialistas+por+especialidade-147.
5. PORDATA: Dados de Portugal Comtemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Taxa+bruta+de+natalidade-527.
6. Programa Nacional de Saúde Infantil e Juvenil. Direção Geral de Saúde. s.l. : Lisboa : Direção Geral de Saúde. , 2013. , Vol. Vol. nº 10/2013.
7. Camara Municipal: Vila Nova de Famalicão. Carta Educativa do Municipio de Vila Nova de Famalicão. Vila Nova de Famalicão : s.n., 2009.
8. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 05 de September de 2015.] http://www.cm-vnfamalicao.pt/_freguesias_7.
9. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_censos_2011__populacao.
10. Gabinete de Estratégia e Planeamento. Carta Social. [Online] [Citação: 5 de September de 2015.] http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false..
11. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015 : s.n.
12. Famalicão, Camara Municipal: Vila Nova de. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_jardins_de_infancia_.
13. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015.
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APPENDIX I: QUESTIONNAIRE
We would like to invite you to participate in a research study designed five Family
Physicians that work in three different health institutions in the county of Vila Nova de Famalicão
(Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-
o-Anjo) and a Public Health Physician. To that effect, your participation would consist of filling
out the questionnaire in the appendix. Its purpose is to know the factors that determine parents’
choice of the physician (Family Physician or Pediatrician) for their children’s surveillance
consultations.
It will be guaranteed the anonymity and confidentiality of the data of all the participants
and they will be used exclusively for the purpose of this study.
The authors thank you for your collaboration.
Ana Faria Couto | Family Medicine Resident in Family Health Unit Familiar S. Miguel-o-Anjo
João Firmino Machado | Public Health Resident in WesternOportoPublicHealthUnit
Joana d’Orey Leça | Family Medicine Resident in Family Health Unit Terras do Ave
Rute Teixeira | Family Physician in Family Health Unit S. Miguel-o-Anjo
Sofia Velho Rua | Family Medicine Resident in Family Health Unit Ribeirão
Susana Rebelo | Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo
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1. Age (type the number): ___________ years
2. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widow
3. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
4. Professional situation
Active
Unemployed
Retired
Student
5. Age (type the number): ___________ years
6. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widower
MOTHER'SIDENTIFICATION
FATHER'SIDENTIFICATION
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1. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
2. Professional situation
Active Unemployed
Retired
Student
Household
3. Number of household members (number of people living in your home): ___________________________
4. How many children do you have? (please take into consideration the mother and the father’s children)____________________________
5. Average monthly household income (after tax)
499 euros or less
from 500 to 999 euros
from 1000 euros to 1999 euros
2000 euros or more
6. Does your child have a private health insurance of his own? Do you have a private
health insurance that includes your child?
Yes No
7. Date of birth of your child (DD/MM/YYYY)
_____/______/__________
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8. Does your child have any chronic disease1?
Yes No I don’t know
9. Does your child have an assigned Family Physician?
Yes No
a. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
10. Does your child have a Pediatrician?
Yes No
a. If so, where?
Public Hospital Private Hospital/ Clinic b. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
1Chronic disease: disease with more than 6 months of duration, which implies more frequent medical follow-up, beyond the surveillance consultations defined in the health record of your child.
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The following questions aim to know your opinion about your Family Physician’s skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
The Family Physician is empowered to conduct surveillance consultations of my son.
The Family Physician has expertise to solve acute/urgent diseases of my son.
It is easy to schedule an appointment with the Family Physician.
It is easy to schedule an appointment on the same day in case of an acute/urgent disease with the Family Physician.
It is easy to talk by telephone with the Family Physician in case of illness.
It is easy to schedule an appointment after working hours in the Family Physician.
Surveillance by the Family Physician is important because of the knowledge that he has about the family context.
Quiz
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The following questions aim to know your opinion about the Pediatrician's skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
I think that the Pediatrician has more knowledge and clinical practice related to children than the Family Physician.
I believe that my son is best followed by a Pediatrician, regardless of the Family Physician’s quality.
I believe that children should always be followed by a Pediatrician, even if simultaneously followed by the Family Physician.
It is easy to schedule an appointment with the Pediatrician.
It is easy to schedule an appointment on the same day with the Pediatrician in case of an acute/urgent disease.
It is easy to talk by telephone with the Pediatrician in case of illness.
It is easy to schedule an appointment after working hours with the Pediatrician.
Thank you for your collaboration!
CompleteonlyifyourchildisfollowedbyaPediatricianinaprivatehospitalorclinic.
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Author’ssignatures_______________________________________________________________________________________________________________________
APPENDIX II: INFORMED CONSENT
Informed Consent Form for Study Participation
according to Declaration of Helsinki2 and Oviedo Convention3
You have been invited to participate in a research study, please read carefully all the information below. If you believe that there is an incorrect or unclear information, do not hesitate to ask for clarification. If you agree to participate, please sign this document.
Title of study: “Are healthy children attended by the family physician or the pediatrician? Determinants of an important decision”
Purpose of the Study: This is a research study designed by five Family Physicians that work in three different health institutions in the county of Vila Nova de Famalicão 8Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-o-Anjo) and a Public Health Physician. The main objective is to know the factors that determine parents’ choice of the physician (Family Physician or Pediatrician) for their children’s surveillance consultations. The study population will comprise parents of pre-school children enrolled in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate in the study. To that effect, your participation will consist of filling out an anonymous questionnaire that will be given to you by the children’s teachers.
Conditions and compensations: There will be no compensations nor prejudice for the participants. The parents’ collaboration is voluntary and, therefore, you are free to refuse to participate. Ethical approval was obtained from the City Council of Vila Nova de Famalicão, in the context of the program Aproximar, as required by national legislation.
Confidentiality and anonymity: It is guaranteed the anonymity and confidentiality of the data of all the participants and they will be used exclusively for the purpose of this study. It was requested and granted authorization of National Data Protection Commission.
The authors thank you for your collaboration.
Susana Rebelo | Family Health Unit S. Miguel-o-Anjo |[email protected] Ana F. Couto | Family Health Unit S. Miguel-o-Anjo | [email protected] João Firmino Machado | Western Oporto Public Health Unit | [email protected] Joana d’Orey Leça | Family Health Unit Terras do Ave | [email protected] Rute Teixeira | Family Health Unit S. Miguel-o-Anjo | [email protected] Sofia Velho Rua | Family Health Unit Ribeirão | [email protected]
-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o- Your signature below indicates that you have read the document and that you confirm all the following:
1. The study has been explained to you and all of your questions have been answered. 2. You understand why the study is being conducted and how it will be performed. 3. You understand that your participation is voluntary and that you can refuse to participate at any
point of the study without any kind of prejudice.
2http://portal.arsnorte.min-saude.pt/portal/page/portal/ARSNorte/Comiss%C3%A3o%20de%20%C3%89tica/Ficheiros/Declaracao_Helsinquia_2008.pdf
3http://dre.pt/pdf1sdip/2001/01/002A00/00140036.pdf
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4. You understand that anonymity and confidentiality will be guaranteed and that all data will be used exclusively for the purpose of the study.
5. You understand your rights and you voluntarily consent to your child’s participation in this study. 6. You have been told you will receive a copy of this form.
Name: … … … … … … … …... … … … …... … … … … … … … … … … … … Signature: … … … … … … … …... … … … … ... … … … … … … … … … … … … Date: …… /…… /………..
THIS IS A 2 PAGE AND DUPLICATED DOCUMENT: ONE COPY FOR THE INVESTIGATOR
AND ONE FOR THE PARTICIPANT
If illiterate: I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Print name of witness: … … … … … …… … … … … … … … Thumb print of participant Signature of witness: … … … … … …… … … … … …… … Date …… /…… /………..
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Is healthy children surveillance being duplicated by Family
Physicians and Paediatricians? A cross-sectional study in
Portugal.
Journal: BMJ Open
Manuscript ID bmjopen-2017-015902.R4
Article Type: Research
Date Submitted by the Author: 02-Jan-2018
Complete List of Authors: Rebelo, Susana; Family Health Unit Rbeirão Velho Rua, Sofia; Family Health Unit Ribeirão d´Orey Leça, Joana ; Family Health Unit Terras do Ave Couto, Ana; Family Health Unit S. Miguel-o-Anjo Teixeira, Rute; Family Health Unit Serzedelo Firmino-Machado, João; EPIUnit; Unidade de Saúde Pública ACeS Porto Ocidental
<b>Primary Subject Heading</b>:
General practice / Family practice
Secondary Subject Heading: Paediatrics
Keywords: Paediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice
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Is healthy children surveillance being duplicated by Family Physicians
and Paediatricians? A cross-sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João Firmino-Machado6
Sofia Velho Rua and Joana d’Orey Leça equally contributed to this article.
1 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Susana Rebelo Family Medicine Res-ident.
2 Family Health Unit Ribeirão, Northern Regional Health Administration, Rua da Extensão de Saúde, 4760-715 Ribeirão, Portugal, Sofia Velho Rua Family Medicine Resident.
3 Family Health Unit Terras do Ave, Northern Regional Health Administration, Rua do Pavilhão, 4765-628 Delães, Portugal, Joana d’Orey Leça Family Medicine Resident.
4 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine Assistant.
5 Family Health Unit S. Miguel-o-Anjo, Northern Regional Health Administration, Avenida Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Rute Teixeira Family Physician Assistant.
6 Western Oporto Public Health Unit, Northern Regional Health Administration, Rua de Vila Nova 503, 4100 Porto; EPI Unit, Rua das Taipas, 4050-600 Porto, Portugal, João Firmino Machado Public Health Resident.
Corresponding to J Machado: [email protected]
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Abstract
OBJECTIVES: To determine if children attend the Family Physician (FP) or the
FP/Paediatrician for their surveillance medical appointments, as well as analyse the variables
associated with the parents’ choice between the two physicians.
DESIGN: Cross-sectional study.
SETTING: Public, semi-private and private kindergartens in the city of Vila Nova de Famalicão
(Portugal).
PARTICIPANTS: Parents of children aged 6 years old or less without chronic diseases, enrolled
in the selected kindergartens,
MAIN OUTCOME MEASURES: Proportion of children attending the FP or FP/Paediatrician
for their surveillance appointments; association between the chosen Physician and
sociodemographic and household variables (parents´ age, educational level, professional
situation and marital status; household net income; number of children; the child´s age;
presence of private health insurance); assessment of the parents' perception of clinical
knowledge and accessibility regarding the Family Physician and the Paediatrician.
RESULTS: A total of 697 children were included in the analysis: 30.6% attended only the FP
and 69.4% attended both the FP and the Paediatrician. Using a Poisson regression, the mother´s
age (PR=1.02, 95% CI 1.00-1.03), higher educational level (PR=1.15, 95% CI 1.00-1.33),
private health insurance (PR=1.30, 95% CI 1.15-1.46), number of children (PR=0.86, 95% CI
0.78-0.94) and the child’s age (PR=0.95, 95% CI 0.91-0.98) were statistically associated with
attending both the FP and the Paediatrician; parents of children who attended only FP rated the
FP with a higher accessibility and knowledge mean score than those who consulted both
physicians (2.91 versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001).
CONCLUSIONS: Our data shows that 70% of our sample simultaneously attended an FP and a
Paediatrician. Family Physicians are equally qualified to provide medical care to healthy
children but this information is not properly transmitted to the general population.
Keywords: Paediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health
Care, Family Practice.
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Strengths and limitations of this study
- To our knowledge, this was the first study addressing the factors associated with parents’
choice in the medical care of their children;
- Our study has an adequate sampling, taking into consideration the three existing school
types: public, semi-private and private;
- The conclusions of our study may be valid in other settings since the population includes
children from different social backgrounds and ages.
- We could only determine the variables associated with attending the FP or the Paediatri-
cian, but not the causes of this decision;
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Introduction:
According to the Robert Graham Center in the United States, the ratio of children’s health care
provided by Family Physicians (FPs) decreased by about 33% between 1992 and 2002, from
one in four children to one in six.1,2 At the same time, there was an increase in the number of
visits to Paediatricians. FPs provide care to approximately 20% of children between birth and 5
years of age, and this proportion increases to nearly 50% for adolescents, compared with 78%
and 44%, respectively, in the case of the Paediatricians.1
FPs located in rural and suburban areas are more likely to provide care to children than those in
areas with a higher density of paediatricians.2,3 Children who do not have health insurance or
public health insurance are also more likely to go to FPs.1 Regarding the physician’s
characteristics, younger age and female sex are positively correlated with medical care being
provided by FPs.3
Currently, the Portuguese health care system is characterised by two coexisting systems: the
public universal National Health Service (NHS) and the private sector. The latter includes
private insurance schemes for certain professions (health subsystems) and voluntary health
insurance. People can also have access to private care without any insurance, paying the total
costs of the care provided. 4-5
The NHS is accessible to all residents in Portugal and provides primary and secondary health
care. It is financed mainly through taxation and tends to be free of charge, but co-payments, that
take into account citizens’ social and economic background, can be charged . However, there
are certain types of appointments free of charge, regardless of individual income, such as
medical appointments for those under the age of 18.5
The National Programme for Child and Juvenile Health establishes 18 surveillance
appointments provided by Primary Care at specific ages, 13 of them on the first 6 years of life.6
Additionally, there is a Portuguese National Vaccination Plan7, which is free of charge and only
accessible through the primary care of NHS.
Portuguese primary health care physicians have a four-year residency training which includes
Paediatrics rotation in secondary care and the normal surveillance of children included in the
Family Physician residency program8. This training enables FPs to monitor healthy children and
identify any disorders that can be either treated in primary care or that require referral to
Paediatrics in secondary care.
In the Portuguese NHS, Paediatricians work in secondary care, and although they are also
qualified to follow healthy children, they mainly assume this role in the private sector.
There is no official data regarding the proportion of children followed simultaneously by FPs in
the NHS and by Paediatricians in the private sector, but it is clear from daily practice that this
choice has been increasing in the past years, leading to duplicated care of healthy children.
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According to the national health survey of 2005/2006, 31,1% of children under fifteen are
followed by Paediatricians in the private sector.9 In 2016, in the county of Vila Nova de
Famalicão, the proportion of children with adequate surveillance by FPs in the first year of life
was 80% and 79,3% in the second year of life.10
The use of multiple care providers is associated with poor continuity of care and excess costs to
the health care system.11 According to the behavioural model developed by Andersen12 the use of
health services is determined by three elements: predisposing factors, enabling factors and
need.12-13 Some studies have shown that parents with higher education level, higher incomes and
active professional status are considered predisposing factors to seek healthcare services for
their children.14-18
Therefore, the main objectives of our study consisted both in determining whether children
attend the FP or the FP/Paediatrician in their surveillance appointments, and in ascertaining the
variables associated with the parents’ choice between the two physicians.
This study has particular significance because, to the best of our knowledge, it is the first study
to be accomplished on this matter.
METHODS:
Study design Since this was a cross-sectional study, in order to determine the factors associated with parental
choices in the medical care of their children, a questionnaire was designed by the researchers.
This questionnaire is enclosed in the supplementary annex, along with the protocol.
As required by national legislation ethical approval was obtained from the City Council of Vila
Nova de Famalicão, regarding public institutions and from the directors of the private and semi-
private kindergartens.
Setting and Study size
The study population comprised all children up to 6 years of age, including those enrolled in
public, semi-private and private kindergartens in the city of Vila Nova de Famalicão, a county
in the north of Portugal.
According to national statistics, in September 2015 there were 4989 children enrolled in the
kindergartens in the city of Vila Nova de Famalicão.19-20 We determined a minimum sample size
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of 536 valid questionnaires using OpenEpi, considering a 50% proportion of children being
attended simultaneously by FPs and Paediatricians, a confidence interval (CI) of 95% and a
design effect of 1.5. A conservative approach, using a 50% prevalence, was considered because
no evidence was available on the proportion of children simultaneously attended by FPs and
Paediatricians, at a national level. We considered that the number of delivered questionnaires
should be three times greater in order to deal with non-delivered questionnaires and the
exclusion criteria which could not be anticipated. At the time, this county comprised 89
kindergartens, 47 of which were public, 29 semi-private and 13 were private.21 We used a
random sample that was stratified by school type – public, semi-private, private. Strata weights
were calculated using the number of students in each specific stratum and the total number of
students in all schools. In each stratum, schools were considered as sampling units and were
randomly chosen with selection probabilities proportional to the number of students. And again,
in each stratum, the school selection process ended when the total number of children was
superior to the determined sample size for each school type. Therefore, all the parents from the
selected schools were invited to participate.
Participants
The parents of children from the selected kindergartens were personally invited to participate
and the purpose of the study was explained to them by the teachers who were previously trained
by the researchers. The parents who accepted to participate signed an informed consent and
received a questionnaire delivered by the preschool teachers between April and May 2016.
Surveys were preferably answered at home by both parents. Anonymity and confidentiality of
all the participants’ data was maintained, as they placed the unidentified questionnaires in a
sealed box. They were then collected by the researchers in June 2016.
We excluded the following children: those with chronic diseases followed by Paediatricians in
public hospitals; those up to 2 years of age who had a Paediatrician, but did not attend their
services in the previous year; and those older than 2 years old who had not had an appointment
in the two preceding years. We also excluded children who did not have an FP and those who
had an FP but did not have adequate monitoring. Based on the National Programme for Child
and Juvenile Health6, children are expected to attend nine surveillance appointments during the
first two years of life, and once a year until the age of 6. Consequently, we established as
inadequate surveillance attending less than 80% of the appointments for children up to 2 years
old, and not having attended the FP in the two previous years for older children in Primary
Care. Incomplete surveys (under 80% of answered questions) were not considered for data
analysis.
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Variables and data collection instrument
The questionnaire consisted of two parts: the first comprised direct questions about the socio-
demographic characteristics related to parents, children and the household. The second part
consisted of statements about accessibility and knowledge regarding the Family Physician and
the Paediatrician, to be rated according to a Likert scale. This scale includes five ordered re-
sponse levels varying between 1 and 5, measuring either negative, neutral or positive response
to a statement. There were three questions about the clinical knowledge and four about the ac-
cessibility regarding each physician. To evaluate knowledge, parents were asked about their
perception for paediatric surveillance and acute/urgent disease management skills for both phy-
sicians. Accessibility was assessed with questions about appointment scheduling (urgent, moni-
toring and after work hours appointments), and the possibility to establish telephone contact
with the physicians.
Content validity was tested with eligible patients and minor modifications were implemented.
Data obtained by this process was not included in data analysis.
We included 13 socio-demographic and household variables in the analyses: parents’ age,
education level; professional situation and marital status; household size and net income;
number of children; child´s age and health insurance situation. Additionally, two more
variables, accessibility and clinical knowledge, related to the FP or Paediatrician, were included.
Statistical methods
For statistical analysis, responders were divided into two groups: children that attended only the
Family Physician (FP group) and children that attended both the Family Physician and the
Paediatrician (FP/Paediatrician group).
Categorical variables are described as frequencies and percentages, and continuous variables as
means and standard deviations.
Differences between FP and FP/Paediatrician groups’ characteristics were tested using a Chi-
squared test for categorical variables and a Student’s t-test for independent samples. The
Multivariable Poisson regression model was used to test an association between socio-
demographic/household variables and FP or FP/Paediatrician groups. This model included as
independent variables those that were clinically supported. The variables father´s age and
household size were not included as they are suspected to be highly correlated, which would
lead to model multi-collinearity.
Perceptions of accessibility and knowledge were compared between FP and FP/Paediatrician
groups using independent t-tests. Additionally, accessibility and knowledge about the Family
Physician and Paediatrician were compared using a paired t-test, only for children who
belonged to the FP/Paediatrician group.
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The sample was treated as complex, considering the processes of stratification and clustering,
and using adequate weighting of cases for all statistical analysis.
The latter was performed with SPSS v23.0 and an α=0.05 was assumed.
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RESULTS
A total of 697 questionnaires were considered for the analysis (Fig 1), 213 (30.6%) from the FP
group and 484 (69.4%) from the FP/Paediatrician group. The global missing data was 1,2% and
for each individual variable it was inferior to 3%.
Table 1 summarizes the socio-demographic and household characteristics of the participants in
the study. We found that the differences between the two groups for all the variables were statis-
tically significant, except for the father´s age (p=0.109). Higher education was more frequent in
the FP/Paediatrician group (42.3% versus 10.4% for the mother, p<0.001, and 24.9% versus
5.4% for the father, p<0.001). The active professional status was more frequent in the
FP/Paediatrician group when compared to the FP group (90% versus 78.3% for the mother,
p<0.001, and 94.8% versus 86.8% for the father, p<0.001). Higher incomes were also more
frequent in the Paediatrician/FP group, with 71.3% having a monthly net income of 1000 euros
(847£; 2245$) or more, compared with only 36.3% in the FP group. Additionally, 45.1% of the
children in the PF/Paediatrician group and only 13.3% in the FP group had private health insur-
ance (p<0.001).
Table 1| Socio-demographic and household characteristics of the participants (n=697)
Total
n= 697
FP group
n= 213
FP/Paediatri
cian group
n= 484
p-
value
Mother’s age (years)
Mean ± SD
34.48 ± 5.73
33.48 ± 5.73
34.75 ± 4.46
<0.001
Mother’s education
Without higher education
With higher education
468 (67.4%) 226 (32.6%)
190 (89.6%) 22 (10.4%)
278 (57.7%) 204 (42.3%)
<0.001
Mother’s professional situa-
tion
Not active
Active
94 (13.5%) 600 (86.5%)
46 (21.7%)
166 (78.3%)
48(10.0%)
434 (90.0%) <0.001
Mother’s marital status
Single
Divorced/separated
Married/cohabiting couples
56 (8.1%)
31 (4.5%)
608 (87.5%)
27 (12.7%) 16 (7.5%)
170 (79.8%)
29 (6.0%)
15 (3.1%)
438 (90.9%)
<0.001
Father’s age (years)
Mean ± SD
36.27 ± 6.04
36.27 ± 6.04
36.84 ± 4.91
0.109
Father’s education
Without higher education
With higher education
556 (80.9%) 131 (19.1%)
194 (94.6%)
11 (5.4%)
362 (75.1%) 120 (24.9%)
<0.001
Father’s professional situation
Not active
Active
52 (7.6%)
634 (92.4%)
27 (13.2%)
177 (86.8%)
25 (5.2%)
457 (94.8%) <0.001
Father’s marital status
Single
Divorced/separated
Married/ cohabiting couples
51 (7.4%) 35 (5.1%)
602 (87.5%)
23 (11.2%) 15 (7.3%)
167 (81.5%)
28 (5.8%) 20 (4.1%)
435 (90.1%)
<0.001
Household net income*
≤500€
39 (5.8%)
24 (11.8%)
15 (3.2%)
<0.001
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*500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; †Number of people living in the same house. ‡Total number of children of both parents. SD: standard deviation; FP: Family Physician.
We adjusted a Poisson regression (table 2) considering as dependent variable attending a FP or
attending a FP/Paediatrician, and as independent variables all those presented in Table 1. We
excluded the father´s age and household size as they were suspected to be highly correlated, and
the parents´ marital state due to lack of clinical relevance. Variables such as mother´s
educational level and age, private health insurance, number of children and children´s age
remained statistically associated with attending both physicians, with a prevalence ratio (PR) of
1.02 for the mother´s age (95% CI 1.00-1.03); 1.15 for the mother's educational level (95% CI
1.00-1.33); 1.30 for having a private health insurance (95% CI 1.15-1.46); 0.86 for the number
of children (95% CI 0.78-0.94) and 0.95 for the child´s age (95% CI 0.91-0.98). There was no
significant association between the household income [PR=1.24 (95% CI 0.82-1.87) for
incomes under 500 euros; PR=1.14 (95% CI 0.78-1.65) for incomes between 501 and 999
euros; PR= 0.94 (95% CI 0.65-1.37) for incomes between 1000 and 1999], the mother’s
professional situation (PR=1.24, 95% CI 0.99-1.54), the father´s educational level (PR=1.12,
95% CI 0.95-1.32), the father´s professional situation (PR=1.28, 95% CI 0.96-1.70) and the
outcome.
Table 2| Poisson regression for determination of variables associated with FP and FP/Paediatrician group.
Independent variables
PR
95% CI for PR
Mother´s age (years) 1.02 1.00-1.03
Mother’s education
Without higher education
With higher education
1
1.15
—
1.00 – 1.33 Mother’s professional situation
Not active
Active
1
1.24
—
0.99 – 1.54 Father’s education
Without higher education
With higher education
1
1.12
—
0.95 – 1.32
501 to 999€ 1000 to 1999€
≥2000€
225 (33.5%) 318 (47.4%) 89 (13.3%)
106 (52.0%) 70 (34.3%) 4 (2.0%)
119 (25.5%) 248 (53.1%) 85 (18.2%)
Private health insurance
No
Yes
449 (64.6%) 246 (35.4%)
184 (86.8%) 28 (13.2%)
265 (54.9%) 218 (45.1%)
<0.001
Household size†
Mean ± SD
3.64 ± 0.78
3.79 ± 0.79
3.56 ± 0.74
<0.001
Number of children‡
Mean ± SD
1.83 ± 0.77
1.83 ± 0.78
1.57 ± 0.66
<0.001
Child’s age (years)
Mean ± SD
3.50 ± 1.69
3.87 ± 1.58
3.34 ± 1.71
<0.001
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Father’s professional situation
Not active
Active
1
1.28
—
0.96 – 1.70 Household net income*
≤500€
501 to 999€ 1000 to 1999€
≥2000€
1.24 1.14 0.94
1
0.82 – 1.87 0.78 – 1.65 0.65 – 1.37
— Private health insurance
No
Yes
1
1.30
—
1.15 – 1.46 Number of children‡ 0.86 0.78 – 0.94 Child’s age (years) 0.95 0.91 – 0.98
*500€ (423£; 562$) corresponds to approximately one national minimum wage; 1000€ = 847£/ 1123$; 2000€ =1693£/ 2246$; ‡Total number of children of both parents. PR: Prevalence ratio. CI: Confidence interval. The FP group was considered as the reference group for the Poisson regression. The variables father´s age and household size were not included as they are suspected to be highly correlated, contributing to model multi-collinearity. The parents’ marital status was not included due to lack of clinical relevance.
Regarding the parents’ perception about accessibility and clinical knowledge of the physicians,
we found statistical differences between the two groups (table 3). The FP group rated the FP
with a higher accessibility and knowledge mean score comparing with FP/Paediatrician group
(2.91 versus 2.38, p<0.001, and 4.11 versus 3.85, p<0.001). In the FP/Paediatrician group, the
mean score of accessibility and knowledge was significantly higher for the Paediatrician
comparing with the FP (4.29 versus 2.53, p<0.001, and 4.11 versus 3.85, p<0.001).
Table 3| Parents’ perception on accessibility and knowledge of the Family Physician and the Paediatrician.
Items about Knowledge related to
the: Items about Accessibility related to
the:
Family Physician Paediatrician Family Physician Paediatrician
Participants with Family Physician
4.11 ± 0.87* ------ (a)
2.91 ± 1.10* ------
(a)
Participants with Family Physician and Paediatrician
3.85 ± 0.87*
4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.77*
*mean ± standard deviation; (a) – did not have a Paediatrician
p<0.001 p<0.001 p<0.001 p<0.001
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Discussion
In our study, only about 30% of the children attended exclusively the FP for surveillance ap-
pointments, and 70% of the sample attended both the FP and the Paediatrician.
We found that the mother´s age and her educational level, private health insurance, number of
children and the child’s age were associated with attending both the FP and the Paediatrician.
The variable with higher impact in the parents’ choice was having a private health insurance
(PR= 1.30, 95% CI 1.15 – 1.46). Both mother´s age and her educational level were statistically
associated with attending both physicians. However, father´s age and his educational level were
not associated with the parents’ choice. This could be explained by social and cultural influ-
ences in Portugal where the mother is still considered as the centre of nurture and care in the
family life. Additionally, both the number of children and the child´s age were also associated
with the parents’ choice. We think this may be explained by a higher experience as children
grow older, and the parent’s awareness about the child’s health. Furthermore, economic reasons
may influence this choice as the number of children grows. Our results are supported by the
Robert Graham Center study1 findings: the proportion of children attending the Paediatrician
decreases as children grow older and children with private health insurance are more likely to
attend the Paediatrician. Regarding the parents’ perception of accessibility and the clinical
knowledge of the Family Physician and the Paediatrician, we found statistical differences be-
tween the two groups. Parents who attended both physicians rated the FP with lower accessibil-
ity and knowledge than those who consulted only the FP.
Strengths and limitations
To the best of our knowledge, there are no previous studies available regarding the factors asso-
ciated with parents’ choice in the medical care of their children, so this is the first one address-
ing this important subject. Other strengths of our study are an adequate sampling, taking into
consideration the three existing school types: public, semi-private and private.
The main limitation found by the researchers was that only the variables associated with attend-
ing the FP or the Paediatrician were determined. The causes of this outcome could not be de-
termined as causality cannot be evaluated with this study design.
Conclusions and implications for future research and practice
We identified variables associated with the parents’ choice in the medical care of their children
and having private health insurance was the most relevant one.
Our data shows that Family Physicians still play an important role in children’s follow-up, even
though approximately 70% of our sample simultaneously attended a Paediatrician. This can
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translate into a duplication of care and costs.
Unlike Paediatricians, the role of FPs is still unclear to most parents since they rated the FP with
a lower average clinical knowledge than the Paediatrician. However, Family Physicians and
Paediatricians are equally qualified to provide medical care to children without chronic diseases,
with the advantage that costs associated with the same surveillance appointments are lower
when carried out in Primary Health Care.22-25 Moreover, we believe that these facts should be
advertised and included in the health care promotion and education provided to parents and the
general population.
The conclusions of our study may be valid in other settings: the population is highly compre-
hensive since it includes children from different social stratum and ages.
Additional investigation is relevant to understand if children’s medical care provided simulta-
neously by a Paediatrician and an FP is associated with health benefits and higher public health
costs when compared to medical care provided exclusively by the FP.
Footnotes
We would like to thank the City Council of Vila Nova de Famalicão, and acknowledge the con-
tribution of the institutions that participated in the study as well as the willingness of all the
parents who kindly answered the questionnaire.
Contributors: The authors SR, SVR, JOL, AC, RT and JFM designed the study concept, wrote
the protocol and collected the data. All authors contributed to the questionnaire validation and
data collection. SR and FM conducted the analyses. All authors helped to draft the manuscript,
read and approve the final manuscript. All authors had full access to all data (including statisti-
cal reports and tables) in the study and can take responsibility for the integrity of the data and
the accuracy of the data analysis. SVR and JOL equally contributed to this article. SR and FM
are the study guarantors
Carolina Gonçalves, Lucélia Campinho, Susana Vilar Santos, Vasco Duarte and Juliana Couto
were collaborators in the study. Carolina Gonçalves contributed to the study design. Lucélia
Campinho, Susana Vilar Santos and Vasco Duarte contributed both to questionnaire validation
and data collection. Juliana Couto corrected the final manuscript.
Funding: This study did not receive any external funding
Competing interests: None declared.
Contributorship Statement: All authors completed the ICMJE uniform disclosure form at
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www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
Ethical approval: Ethical approval was obtained from the City Council of Vila Nova de Fama-
licão, in the context of the programme “Aproximar”, as required by national legislation.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the manu-
script is an honest, accurate, and transparent account of the study being reported; that no im-
portant aspects of the study have been omitted; and that any discrepancies from the study as
planned have been registered.
Data sharing: questionnaire available on request to the corresponding author.
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14. Burokienė S, Raistenskis J, Burokaitė E, Čerkauskienė R, Usonis V. Factors Determining Parents’ Decisions to Bring Their Children to the Pediatric Emergency Department for a Minor Illness. Medical Science Monitor. 2017; 23: 4141–4148.
15. Abdulkadir M, Ibraheem R, Johnson W. Sociodemographic and Clinical Determinants of Time to Care-Seeking Among Febrile Children Under-Five in North-Central Nigeria. Oman Medical Journal. 2015 Sep; 30(5): 331–335.
16. Wysocki, T., & Gavin, L. Psychometric properties of a new measure of fathers’ involvement in the management of pediatric chronic diseases. Journal of Pediatric Psychology. 2004; 29(3): 231-240.
17. Blumberg, S.J., Halfon, N., & Olson, L.M. 2004. The national survey of early childhood health. Pediatrics, 113(6): 1899-1906.
18. Abdulkadir M, Abdulkadir Z. A cross-sectional survey of parental care-seeking behav-ior for febrile illness among under-five children in Nigeria. Alexandria Journal of Medicine. 2017; 53 (1): 85-91.
19. Gabinete de Estratégia e Planeamento. Carta Social. Resposta Social: Creche – Equipamentos existentes no Distrito de Braga, Concelho de Vila Nova de Famalicão. Available on: http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&lo
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calpostal=&temCert=false (accessed on 5 September 2015). 20. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014,
Volume I: Norte. Posrtugal, Lisbon 2015; 197-200. 21. Câmara Municipal de Vila Nova de Famalicão. Jardins-de-infância. Available on:
http://www.cm-vnfamalicao.pt/_jardins_de_infancia_2 (accessed on 5 September 2015).
22. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 2005; 83(3): 457–502.
23. Franks P, Fiscella K. Primary care physicians and specialists as personal physicians. Health care expenditures and mortality experience. The Journal of Family Practice 1998; 47(2):105-9.
24. Mark DH, Gottlieb MS, Zellner BB, Chetty VK, Midtling JE. Medicare costs in urban areas and the supply of primary care physicians. The Journal of Family Practice 1996; 43(1):33-9.
25. Doescher MP, Franks P, Saver BG. Is family care associated with reduced health care expenditures? he Journal of Family Practice 1999; 48(8):608-14.
Figure Legends:
Fig 1| Flowchart showing the sample selection.
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Fig 1| Flowchart showing the sample selection.
210x297mm (300 x 300 DPI)
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua , Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino-Machado.
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Authors:
1- Susana Rebelo (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 2- Sofia Velho Rua (Family Medicine Resident in Family Health Unit Ribeirão) 3- Joana d’Orey Leça (Family Medicine Resident in Family Health Unit Terras do Ave) 4- Ana Faria Couto (Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo) 5- Rute Teixeira (Family Physician in Family Health Unit S. Miguel-o-Anjo) 6- Joõa Firmino-Machado (Public Health Resident in WesternOportoPublicHealthUnit)
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Index
LIST of ABBREVIATIONS.........................................................................................................................................4
ABSTRACT........................................................................................................................................................................5
INTRODUCTION.............................................................................................................................................................6
OBJECTIVES.....................................................................................................................................................................7
POPULATION...................................................................................................................................................................7
SAMPLE..............................................................................................................................................................................7
Sampling technique..................................................................................................................................7Sample size...............................................................................................................................................8
PARTICIPANTS...............................................................................................................................................................8
VARIABLES....................................................................................................................................................................10
METHODS........................................................................................................................................................................12
Study location.........................................................................................................................................12Type, duration and study period.............................................................................................................12Study design...........................................................................................................................................12Pilot study..............................................................................................................................................12
COLLABORATOR’S TRAINING...........................................................................................................................13
STATISTICAL ANALYSIS.......................................................................................................................................13
STUDY TIMELINE:......................................................................................................................................................14
MANAGEMENT AND BUDGET............................................................................................................................15
AUTHORS........................................................................................................................................................................15
REFERENCES.................................................................................................................................................................15
APPENDIX I: QUESTIONNAIRE...........................................................................................................................17
APPENDIX II: INFORMED CONSENT...............................................................................................................23
Informed Consent Form for Study Participation....................................................................................23
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LIST OF ABBREVIATIONS
ACeS – Agrupamento de Centros de Saúde
FP – Family Physician
OR – Odds Ratio
PHC - Primary Health Care
USF – Unidade de Saúde Familiar
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ARE HEALTHY CHILDREN ATTENDED BY THE FAMILY PHYSICIAN OR THE PEDIATRICIAN? DETERMINANTS OF AN IMPORTANT DECISION
Susana Rebelo, Sofia Velho Rua, Joana d’Orey Leça, Ana F. Couto, Rute Teixeira, João Firmino Machado.
ABSTRACT
Introduction: In the United States, the ratio of children’s health care provided by Family
Physicians (FPs) decreased by about 33% between 1992 and 2002, from one in four children to
one in six, and, at the same time, there was a significant growth in the number of visits provided
by Pediatricians.
Objectives: To determine if children attend the FP or the Pediatrician for their surveillance
consultations, as well as the variables associated with the parents’ choice between the FP and the
Pediatrician.
Methods and Analysis: Cross sectional analytical study, with an expected duration of one year
and two months. The study population will comprise all parents of pre-school children enrolled
in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate
in the study. The kindergartens will be randomly selected until a statistically significant sample
is obtained. The authors will contact each institution and assess the interest in participating in the
study. Between April and May 2016 all parents of the selected institutions will be invited to
participate in the study. They will have to sign an informed consent and receive a questionnaire
that was created by the investigators and that will be validated by a previous pilot study. The filled
questionnaires will be placed in a sealed box and the investigators will collect them in June 2016.
Statistical analysis will be performed with SPSS v23.0.
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INTRODUCTION
Primary Health Care (PHC) is ideally the first point of contact that a patient has with the
health care system. It has a key role in care providing as it assumes a longitudinal continuity of
care, from birth till death, and a holistic approach of the patient, taking into account his familiar,
social, economic, professional, cultural and many other aspects that comprise his context.
The Family Physician attends patients from both sexes, all age groups, ethnicities, races
and socio-economic levels. However, the age group that includes children from 0 to 18 years
assumes particular importance in PHC. It is a priority group that justifies a bigger effort and
willingness by health providers.
In the United States, the ratio of children’s health care provided by Family Physicians
(FPs) decreased by about 33% between 1992 and 2002, from one in four children to one in six (1;
2) and, at the same time, there was a significant growth in the number of visits provided by
Pediatricians. FPs provide care to approximately 16% of the children between birth and 5 years
of age, compared with 73% in the case of the Pediatricians (1).
FPs located in rural and underserved urban areas are more likely to provide care to
children than those in areas with higher pediatrician density (2; 3). Children without private health
insurance or with public health insurance are also more likely to be attended by FPs (1). Regarding
the physician’s characteristics, younger age and female sex are positive predictors for medical
care being provided by FPs (3).
In Portugal, from 1992 to 2015 the number of Pediatricians and FPs(4) more than doubled
and the birth rate declined from 11,5 to 8,3 live births per 1000 persons (5). The National Program
for Child and Juvenile Health (6) establishes 18 surveillance consultations at specific ages, 13 of
them on the first 6 years of life. These consultations are intended to be done in the Primary Health
Care system but, even though there are no official numbers, it is clear that the number of children
who are simultaneously attended by a Pediatrician in private care is rising.
Therefore, the main objectives of our study are to determine if children attend the FP or
the Pediatrician for their surveillance consultations, as well as the variables associated with the
parents’ choice between the FP and the Pediatrician. This takes particular importance since it is
the first study to be done on this matter.
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OBJECTIVES
1. To determine the variables related to the parents’ choice of the physician (Family
Physician or Pediatrician) for the surveillance consultations of their children.
2. To determine if there is an association between the choice of the physician and the
following variables:
• Parents´ age
• Parents´ educational level
• Parents´ professional situation
• Parents´ marital status
• Household net income
• Household size
• Number of children
• Child’s age
• Presence of private health insurance
3. To assess the parents' perception of the scientific and clinical knowledge, as well as the
accessibility to the physician (FP or Pediatrician).
POPULATION Vila Nova de Famalicão is a town and municipality in the district of Braga, in the north
of Portugal. It has an area of 201.8 km² (7), distributed between 34 civil parishes (8). In 2011, the
population was 133,832 (9).
According to national statistics, in September of 2015, there were 4989 children enrolled
in the kindergartens in the municipality of Vila Nova de Famalicão. This population was
calculated using the data published in Carta Social (10) and the document “Regiões em Números
2013/2014, Volume I-Norte” (11), of the Direção Geral de Estatísticas e da Educação e Ciências.
According to those documents, there were about 1517 children attending kindergartens (10) (up to 3 years old) and approximately 3472 children in pre-school education (3-6 years) (11).
SAMPLE Sampling technique
According to the City Council of Vila Nova de Famalicão (12), there were 89 kindergartens
and pre-school in the county, of which 13 were private, 29 semi-private and 47 public.
We randomized a sample that was stratified by school type – public, semi-public, private. In each
strata, schools were considered as sampling units and were randomly selected with selection
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probabilities proportional to the number of students. For each school, all the parents were invited
to participate.
Sample size
We determined a minimum sample size of 536 valid questionnaires using OpenEpi, using a
prevalence of 50%, a confidence interval (CI) of 95% and a design effect of 1.5. At the time, this
county had 89 kindergartens, 13 were private, 29 semi-private and 47 public (12). We considered
that the number of delivered questionnaires should be three times greater in order to deal with
non-delivered questionnaires and the exclusion criteria, that could not be anticipated. We used a
random sample that was stratified by school type – public, semi-public, private. Strata weights
were calculating the number of students in each specific stratum and the total number of students
in all schools. In each strata, schools were considered as sampling units and were randomly
selected with selection probabilities proportional to the number of students. In each stratum school
selection process ended when the total number of children was superior to the determined sample
size, for each school type. For each school, all the parents were invited to participate.
PARTICIPANTS The study participants will comprise all parents, of the selected kindergartens, with children up
to and including those with 6 years old.
Inclusion criteria
• Parents of children up to and including those with 6 years old, enrolled in public, semi-
private and private kindergartens in the city of Vila Nova de Famalicão
• Parents who agree to take part in the study.
Exclusion criteria
• Children with chronic diseases followed by Pediatricians.
• Children in public hospital following.
• Children up to 2 years old who had a Pediatrician but did not attend their services in the
last year.
• Children older than 2 years old who had a Pediatrician but did not attend their services in
the last two years.
• Children who did not have a FP.
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• Children with a FP but did not had adequate surveillance
• Surveys with more than 20% of unanswered questions
Based on The National Program for Child and Juvenile Health (6), we defined inadequate
surveillance as attending less than 80% of the consultations for children up to 2 years old and not
attending the FP in the last 2 years for older children.
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VARIABLES
The study variables, their operational definition, the type and the values that the variable can take are described in detail in Table 1.
Table 1 – Operational definition, type, acceptable values and coding of the variables under study.
Variable Definition Variable type Values that the variable can take
Child´s physician Physician responsible for the surveillance consultations Categorical
nominal
FP group
FP/Pediatrician group
Mother´s age Number of years between the date of birth and the date of data collection Continuous
Mother´s educational
level
Mother’s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Mother’s professional
situation
Employment situation of mother at the time of data collection Categorical
nominal
Not active
Active
Mother´s marital
status
Mother´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Father´s age Number of years between the date of birth and the date of data collection Continuous
Father´s educational
level
Father´s highest level of education completed Categorical
Ordinal
Without higher education
With higher education
Father’s professional
situation
Employment situation of father at the time of data collection Categorical
nominal
Not active
Active
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Father´s marital
status
Father´s situation in relation to marriage or marital society
Categorical
nominal
Single
Divorced or separated
Married or unmarried partners
Widower
Household net income
Monthly net income of the household, in euros. Categorical
Ordinal
≤500€
501 to 999€
1000 to 1999€
≥2000€
Private health
insurance
Private health insurance that includes the child or child with his own private
health insurance
Categorical Yes
No
Household size Number of people living in the same house. Continuous
Number of children Total number of children of the mother and the father Continuous
Child´s age (months) Number of months between the date of birth and the date of data collection Continuous
FP’s knowledge Parents’ perception about the scientific and clinical knowledge of the FP. Categorical
Ordinal
1-5
Pediatrician’s
knowledge
Parents’ perception about the scientific and clinical knowledge of the
Pediatrician.
Categorical
Ordinal
1-5
FP’s accessibility Parents’ perception about the accessibility to the FP. Categorical
Ordinal
1-5
Pediatrician’s
accessibility
Parents’ perception about the accessibility to the Pediatrician. Categorical
Ordinal
1-5
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METHODS
Study location
Selected kindergartens and pre-schools institutions in Vila Nova de Famalicão.
Type, duration and study period
Cross sectional analytical study, with an expected duration of one year and five months
(from June 2015 to November 2016).
Study design
Parents of children enrolled in the selected kindergartens will be invited to participate and
the purpose of the study will be explained to them by the teachers, who will be previously trained
by the investigators. The parents who accept to participate will sign an informed consent and
receive a questionnaire, which will be delivered by the preschool teachers between April and May
of 2016. Surveys must be answered at home by both parents, if possible. It will be guaranteed the
anonymity and confidentiality of the data of all the participants, as they will place the unidentified
questionnaires in a sealed box. The sealed boxes will be collected by the investigators in June
2016.
In order to determine the factors associated with parents’ choices in the medical care of
their children, a questionnaire was created by the investigators (Appendix I). This consists of two
parts: the first comprises direct questions about the sociodemographic characteristics related to
parents, children and the household. The second part consists of statements about accessibility
and knowledge, regarding the Family Physician and the Pediatrician, to be rated according to a
Likert scale. This scale includes five ordered response levels varying between 1 and 5. A pilot
study will be conducted in the eligible population to test content validity.
Pilot study
A pilot study will be conducted in the eligible population to test content validity. The pilot
study will be conducted in February 2016 and it will consist on applying the questionnaire in the
eligible population followed by an interview, in a small sample (approximately 30 persons). In
the interview, it will be discussed with the participants, topics as the time necessary for the
questionnaire, the question’s format and pertinence, and all the comments that they feel
appropriate, and if necessary, changes will be made in the questionnaire to its final version.
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COLLABORATOR’S TRAINING
It will take place in a multidisciplinary meeting in every institution that accepts to
participate in the study and it will consist on presenting to the teachers the study objectives,
duration and timeline, population and the inclusion and exclusion criteria, and clarification of any
question that might occur. In every meeting, there will be at least two members of the
investigation team present.
The teachers that accept to participate will be asked to sign a declaration of commitment.
STATISTICAL ANALYSIS For statistical analysis, the sample will be divided in two groups: children that attended
only the Family Physician (FP group) and children that attended both the Family Physician and
the Pediatrician (FP/Pediatrician group).
Categorical variables are described as frequencies and percentages and continuous
variables as means and standard deviations. Shapiro-Wilk test will be used to test for normality.
Differences between FP and FP/Pediatrician groups’ characteristics will be tested using qui-
square test or independent sample T-test, as appropriate. Multivariate binary logistic regression
model will be used to determine the variables associated with FP or FP/Pediatrician group. This
model will include as independent variables only those identified by univariate analysis, with p-
values <0,1.
Perceptions of accessibility and knowledge will be compared between FP and
FP/Pediatrician groups using independent T-tests. Additionally, accessibility and knowledge
about the Family Physician and Pediatrician will be compared using a paired sample T-test, only
for children who belong to the FP/Pediatrician group.
Statistical analysis will be performed with SPSS v23.0 and p<0,05 will be defined as
statistically significant.
:
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STUDY TIMELINE:
The data collection process will be held according to the following steps:
Table 1 – Study timeline
2015 2016
June - December January February March April May June July August September November
Protocol and questionnaire design
Submission to ethical approval
Contact with the director of the selected kindergartens and pre-schools
Collaborators’ training
Pilot study
Questionnaires delivery
Data analysis and results discussion
Release of the results
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MANAGEMENT AND BUDGET
The study authors are responsible for the protocol design, collaborators’ training, data
analysis and release of the results. Table 2 shows the required material and budget to the
implementation of the study. All costs of the study will be supported by the authors.
Table 2 – Study material and budget.
Material Unitary Cost (€) x Number of unites required
Cost (€)
Informed consent 0.03 x 4 x 1400 168
Questionnaires (A4) 0.03 x 6 x 1400 252
Travel expenses 200 200
Other expenses 300 300
Total cost - 920
AUTHORS
Susana Rebelo (Family Health Unit S. Miguel-o-Anjo) Ana Faria Couto (Family Health Unit S. Miguel-o-Anjo) Joana d’Orey Leça (Family Health Unit Terras do Ave) Sofia Velho Rua (Family Health Unit Ribeirão) Rute Teixeira (Family Health Unit S. Miguel-o-Anjo) Firmino Machado (Western Oporto Public Health Unit)
REFERENCES
1. Report to the Task Force on the Care of Children by Family Physicians. Phillips RL, Dodoo MS, McCann JL, Bazemore A, Fryer GE, Klein LS, Weitzman M, Green L. s.l. : The Robert Graham Center: Policy Studies in Family Medicine and Primary Care In collaboration with the American Academy of Pediatrics Center for Child Health Research, 2005.
2. Declining Numbers of Family Physicians are Caring for Children. Bazemore A, Makaroff L, Puffer J, Parhat P, Phillips R, Xirali I, Rinaldo J. 2012, Journal of the American Board of Family Medicine, Vols. 25, No 2, pp. 139-140.
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3. Factors Influencing Family Physician´s Contribution to the Child Health Care Workforce. Makaroff LA, Xierali IM, Petterson S, Shipman S, Puffer J, Bazemore A. 2014, Annals of Family Medicine, Vols. 12, No 5.
4. PORDATA: Base de Dados Portugal Contemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Médicos+não+especialistas+e+especialistas+por+especialidade-147.
5. PORDATA: Dados de Portugal Comtemporâneo. PORDATA. [Online] [Citação: 5 de September de 2015.] http://www.pordata.pt/Portugal/Taxa+bruta+de+natalidade-527.
6. Programa Nacional de Saúde Infantil e Juvenil. Direção Geral de Saúde. s.l. : Lisboa : Direção Geral de Saúde. , 2013. , Vol. Vol. nº 10/2013.
7. Camara Municipal: Vila Nova de Famalicão. Carta Educativa do Municipio de Vila Nova de Famalicão. Vila Nova de Famalicão : s.n., 2009.
8. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 05 de September de 2015.] http://www.cm-vnfamalicao.pt/_freguesias_7.
9. Camara Municipal: Vila Nova de Famalicão. Camara Municipal: Vila Nova de Famalicão. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_censos_2011__populacao.
10. Gabinete de Estratégia e Planeamento. Carta Social. [Online] [Citação: 5 de September de 2015.] http://www.cartasocial.pt/resultados_pesquisageral.php?filtrar=hidden&cod_distrito=03&cod_concelho=12&cod_freguesia=0&cod_area=11&cod_valencia=1103&nome=&localpostal=&temCert=false..
11. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015 : s.n.
12. Famalicão, Camara Municipal: Vila Nova de. [Online] [Citação: 5 de September de 2015.] http://www.cm-vnfamalicao.pt/_jardins_de_infancia_.
13. Direção Geral de Estatísticas da Educação e Ciência. Regiões em Números 2013/2014, Volume I: Norte. 2015.
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APPENDIX I: QUESTIONNAIRE
We would like to invite you to participate in a research study designed five Family
Physicians that work in three different health institutions in the county of Vila Nova de Famalicão
(Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-
o-Anjo) and a Public Health Physician. To that effect, your participation would consist of filling
out the questionnaire in the appendix. Its purpose is to know the factors that determine parents’
choice of the physician (Family Physician or Pediatrician) for their children’s surveillance
consultations.
It will be guaranteed the anonymity and confidentiality of the data of all the participants
and they will be used exclusively for the purpose of this study.
The authors thank you for your collaboration.
Ana Faria Couto | Family Medicine Resident in Family Health Unit Familiar S. Miguel-o-Anjo
João Firmino Machado | Public Health Resident in WesternOportoPublicHealthUnit
Joana d’Orey Leça | Family Medicine Resident in Family Health Unit Terras do Ave
Rute Teixeira | Family Physician in Family Health Unit S. Miguel-o-Anjo
Sofia Velho Rua | Family Medicine Resident in Family Health Unit Ribeirão
Susana Rebelo | Family Medicine Resident in Family Health Unit S. Miguel-o-Anjo
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1. Age (type the number): ___________ years
2. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widow
3. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
4. Professional situation
Active
Unemployed
Retired
Student
5. Age (type the number): ___________ years
6. Marital Status:
Single
Divorced or separated
Married or cohabitingcouples
Widower
MOTHER'SIDENTIFICATION
FATHER'SIDENTIFICATION
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1. Highest level of education completed:
Can not read or write
4th grade
6th grade
9th grade
12th grade
Higher education
Another. Which? _________________________________
2. Professional situation
Active Unemployed
Retired
Student
Household
3. Number of household members (number of people living in your home): ___________________________
4. How many children do you have? (please take into consideration the mother and the father’s children)____________________________
5. Average monthly household income (after tax)
499 euros or less
from 500 to 999 euros
from 1000 euros to 1999 euros
2000 euros or more
6. Does your child have a private health insurance of his own? Do you have a private
health insurance that includes your child?
Yes No
7. Date of birth of your child (DD/MM/YYYY)
_____/______/__________
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8. Does your child have any chronic disease1?
Yes No I don’t know
9. Does your child have an assigned Family Physician?
Yes No
a. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
10. Does your child have a Pediatrician?
Yes No
a. If so, where?
Public Hospital Private Hospital/ Clinic b. Mark with (X) the consultations he/she attended according to his/her age:
Less than a month
1 month 2 months 4 months 6 months 9 months 12 months
15 mouths 18 months
2 years 3 years 4 years 5 to 6 years
Others
1Chronic disease: disease with more than 6 months of duration, which implies more frequent medical follow-up, beyond the surveillance consultations defined in the health record of your child.
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The following questions aim to know your opinion about your Family Physician’s skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
The Family Physician is empowered to conduct surveillance consultations of my son.
The Family Physician has expertise to solve acute/urgent diseases of my son.
It is easy to schedule an appointment with the Family Physician.
It is easy to schedule an appointment on the same day in case of an acute/urgent disease with the Family Physician.
It is easy to talk by telephone with the Family Physician in case of illness.
It is easy to schedule an appointment after working hours in the Family Physician.
Surveillance by the Family Physician is important because of the knowledge that he has about the family context.
Quiz
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The following questions aim to know your opinion about the Pediatrician's skills. Please choose the level of agreement with each statement.
1 - Strongly disagree
2 - Disagree
3 - Indifferent
4 - Agree
5 - Strongly agree
1 2 3 4 5
I think that the Pediatrician has more knowledge and clinical practice related to children than the Family Physician.
I believe that my son is best followed by a Pediatrician, regardless of the Family Physician’s quality.
I believe that children should always be followed by a Pediatrician, even if simultaneously followed by the Family Physician.
It is easy to schedule an appointment with the Pediatrician.
It is easy to schedule an appointment on the same day with the Pediatrician in case of an acute/urgent disease.
It is easy to talk by telephone with the Pediatrician in case of illness.
It is easy to schedule an appointment after working hours with the Pediatrician.
Thank you for your collaboration!
CompleteonlyifyourchildisfollowedbyaPediatricianinaprivatehospitalorclinic.
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Author’ssignatures_______________________________________________________________________________________________________________________
APPENDIX II: INFORMED CONSENT
Informed Consent Form for Study Participation
according to Declaration of Helsinki2 and Oviedo Convention3
You have been invited to participate in a research study, please read carefully all the information below. If you believe that there is an incorrect or unclear information, do not hesitate to ask for clarification. If you agree to participate, please sign this document.
Title of study: “Are healthy children attended by the family physician or the pediatrician? Determinants of an important decision”
Purpose of the Study: This is a research study designed by five Family Physicians that work in three different health institutions in the county of Vila Nova de Famalicão 8Family Health Unit Terras do Ave, Family Health Unit Ribeirão, Family Health Unit S. Miguel-o-Anjo) and a Public Health Physician. The main objective is to know the factors that determine parents’ choice of the physician (Family Physician or Pediatrician) for their children’s surveillance consultations. The study population will comprise parents of pre-school children enrolled in public and private kindergartens in the city of Vila Nova de Famalicão that accept to participate in the study. To that effect, your participation will consist of filling out an anonymous questionnaire that will be given to you by the children’s teachers.
Conditions and compensations: There will be no compensations nor prejudice for the participants. The parents’ collaboration is voluntary and, therefore, you are free to refuse to participate. Ethical approval was obtained from the City Council of Vila Nova de Famalicão, in the context of the program Aproximar, as required by national legislation.
Confidentiality and anonymity: It is guaranteed the anonymity and confidentiality of the data of all the participants and they will be used exclusively for the purpose of this study. It was requested and granted authorization of National Data Protection Commission.
The authors thank you for your collaboration.
Susana Rebelo | Family Health Unit S. Miguel-o-Anjo |[email protected] Ana F. Couto | Family Health Unit S. Miguel-o-Anjo | [email protected] João Firmino Machado | Western Oporto Public Health Unit | [email protected] Joana d’Orey Leça | Family Health Unit Terras do Ave | [email protected] Rute Teixeira | Family Health Unit S. Miguel-o-Anjo | [email protected] Sofia Velho Rua | Family Health Unit Ribeirão | [email protected]
-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o-o- Your signature below indicates that you have read the document and that you confirm all the following:
1. The study has been explained to you and all of your questions have been answered. 2. You understand why the study is being conducted and how it will be performed. 3. You understand that your participation is voluntary and that you can refuse to participate at any
point of the study without any kind of prejudice.
2http://portal.arsnorte.min-saude.pt/portal/page/portal/ARSNorte/Comiss%C3%A3o%20de%20%C3%89tica/Ficheiros/Declaracao_Helsinquia_2008.pdf
3http://dre.pt/pdf1sdip/2001/01/002A00/00140036.pdf
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4. You understand that anonymity and confidentiality will be guaranteed and that all data will be used exclusively for the purpose of the study.
5. You understand your rights and you voluntarily consent to your child’s participation in this study. 6. You have been told you will receive a copy of this form.
Name: … … … … … … … …... … … … …... … … … … … … … … … … … … Signature: … … … … … … … …... … … … … ... … … … … … … … … … … … … Date: …… /…… /………..
THIS IS A 2 PAGE AND DUPLICATED DOCUMENT: ONE COPY FOR THE INVESTIGATOR
AND ONE FOR THE PARTICIPANT
If illiterate: I have witnessed the accurate reading of the consent form to the potential participant, and the individual has had the opportunity to ask questions. I confirm that the individual has given consent freely. Print name of witness: … … … … … …… … … … … … … … Thumb print of participant Signature of witness: … … … … … …… … … … … …… … Date …… /…… /………..
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STROBE Statement
Item
No Recommendation
Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract
– Page 2 (Design: cross sectional study)
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found – Page 2
Introduction
Background/rationale 2 Explain the scientific background and rationale for the investigation being reported –
Page 4 (Introduction – First, second and third paragraphs)
Objectives 3 State specific objectives, including any prespecified hypotheses – Page 4
(Introduction – Fourth paragraph)
Methods
Study design 4 Present key elements of study design early in the paper – Page 4 (Methods: study
design)
Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment,
exposure, follow-up, and data collection – Page 5 (Setting and study design – first
and second paragraphs; Participants – first paragraph)
Participants 6 Cross-sectional study—Give the eligibility criteria, and the sources and methods of
selection of participants – Page 5 (Setting and study design –first and second
paragraph) and Page 6 (first paragraph)
Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect
modifiers. Give diagnostic criteria, if applicable – Page 6 (Statistical methods –
first paragraph)
Data sources/
measurement
8* For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if there is
more than one group – Page 4 (Methods: study design), Page 6 (Variables).
Bias 9 Describe any efforts to address potential sources of bias
Information bias – Page 5 (Participants – first paragraph)
Selection bias – Page 5 (Setting and study design –second paragraph)
Study size 10 Explain how the study size was arrived at – Page 5 (Setting and study design –
second paragraph)
Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable,
describe which groupings were chosen and why – Page 6 (Statistical methods)
Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding -
Page 6 (Statistical methods)
(b) Describe any methods used to examine subgroups and interactions - Page 6
(Statistical methods – third paragraph)
(c) Explain how missing data were addressed - Page 6 (firts paragraph) and Page 7
(Results –first paragraph)
Cross-sectional study—If applicable, describe analytical methods taking account of
sampling strategy - Page 5 (Setting and study design –second paragraph)
(e) Describe any sensitivity analyses – not applicable
Continued on next page
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Results
Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible,
examined for eligibility, confirmed eligible, included in the study, completing follow-up, and
analysed - Page 7 (Figure 1)
(b) Give reasons for non-participation at each stage - Page 7 (Figure 1)
(c) Consider use of a flow diagram - Page 7 (Figure 1)
Descriptive
data
14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information
on exposures and potential confounders – Page 8 (table 1) and Results – second paragraph
(b) Indicate number of participants with missing data for each variable of interest – Page 7
(Results –first paragraph).
Cross-sectional study—Report numbers of outcome events or summary measures - Page 7-8:
results
Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their
precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and
why they were included - Page 9 (first paragraph and table 2)
(b) Report category boundaries when continuous variables were categorized –Page 8 (table 1)
(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful
time period - not applicable
Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity
analyses - not applicable
Discussion
Key results 18 Summarise key results with reference to study objectives – Page 10 (Discussion – first and
second paragraphs)
Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision.
Discuss both direction and magnitude of any potential bias – Page 11 (Strengths and
limitations)
Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity
of analyses, results from similar studies, and other relevant evidence – Page 10 (Discussion –
second paragraph) and Page 11 (Conclusions and implications for future research and
practice)
Generalisability 21 Discuss the generalisability (external validity) of the study results - Page 11 (Conclusions and
implications for future research and practice)
Other information
Funding 22 No funding – page 12
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