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For peer review only

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.


Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine Resident.


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



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




1

2.52

—

1.46 – 4.34

— 0.001


≤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


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


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



BMJ Open on F


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1

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




ident.






Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine

Assistent.



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.


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Abstract






(Portugal).










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).






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- 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 were able to confirm that there is in fact a substantial duplication of care in our

children surveillance.

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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





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.









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





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.





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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7

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.







Statistical methods





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.


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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8

RESULTS





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).


Total

n= 697

FP group

n= 213

FP/Pediatrici

an group

n= 484

p-

value


Mean ± SD

34.48 ± 5.73

33.48 ± 5.73

34.75 ± 4.46

<0.001




468 (67.4%) 226 (32.6%)

190 (89.6%) 22 (10.4%)

278 (57.7%) 204 (42.3%)

<0.001


tion

Not active

Active

94 (13.5%) 600 (86.5%)

46 (21.7%)

166 (78.3%)

48(10.0%)

434 (90.0%) <0.001


Single

Divorced/separated


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


Mean ± SD

36.27 ± 6.04

36.27 ± 6.04

36.84 ± 4.91

0.109




556 (80.9%) 131 (19.1%)

194 (94.6%)

11 (5.4%)

362 (75.1%) 120 (24.9%)

<0.001


Not active

Active

52 (7.6%)

634 (92.4%)

27 (13.2%)

177 (86.8%)

25 (5.2%)

457 (94.8%)

<0.001


Single

Divorced/separated


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


≤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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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).



OR

95% CI for OR

Mother´s age (years) 1.06 1.01-1.12




1

2.11

—

1.27 – 3.52

Mother’s professional situation

Not active

Active

1

1.90

—

0.98 – 3.70




1

2.14

—

0.64 – 7.19


Not active

Active

1

1.97

—

0.86 – 4.55


≤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%)


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


Mean ± SD

1.83 ± 0.77

1.83 ± 0.78

1.57 ± 0.66

<0.001


Mean ± SD

51.41 ± 18.64

52.41± 18.67

45.44 ± 20.19

<0.001

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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.










the:



4.11 ± 0.87* ------ (a)

2.91 ± 1.10* ------

(a)


3.85 ± 0.87*

4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.77*


Discussion




p<0.001 p<0.001 p<0.001 p<0.001

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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













the FP.













though approximately 70% of our sample simultaneously attended a Pediatrician, which can

translate into a duplication of care and costs.


a lower clinical knowledge mean than the Pediatrician. However, Family Physicians and Pedia-

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in health care promotion and education that is provided to parents and general population.



costs when compared to medical care provided exclusively by the FP.

Footnotes


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.


Competing interests: None declared.

Contributorship Statement: All authors have completed the ICMJE uniform disclosure form at








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References






5. Barros P, Machado S, Simões J. Portugal: Health system review. Health Sys-tems in Transition, 2011, 13(4):1–156.



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.







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:


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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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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



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



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



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-


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


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


6. Marital Status:

Single



Widower

MOTHER'SIDENTIFICATION

FATHER'SIDENTIFICATION

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4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


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


15 mouths 18 months


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.


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.


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





Introduction





Methods


design)









first paragraph)

Data sources/

measurement








second paragraph)













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Results






Descriptive

data






results









Discussion


second paragraphs)



limitations)




practice)



Other information


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Physicians and Pediatricians? A cross sectional study in

Portugal.

Journal: BMJ Open



Date Submitted by the Author: 11-Sep-2017







BMJ Open on F


http://bmjopen.bm

j.com/

BM


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1


and Pediatricians? A cross sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João

Firmino-Machado6




ident.






Dom Afonso Henriques 3960, 4760 Famalicão, Portugal, Ana Couto Family Medicine

Assistent.



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.


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Abstract






(Portugal).










and 69.4% attended both the FP and the Pediatrician. Using a multivariable binary logistic


95% CI 1.27–3.52), household net income higher than 2000 euros (OR=5.17, 95% CI 1.02–



associated with attending both the FP and the Pediatrician. Parents of children who attended








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- To our knowledge, this was the first study addressing the factors associated with par-

ents’ choice in the medical care of their children


types: public, semi-private and private.



- We were able to confirm that there is in fact a substantial duplication of care in our

children surveillance.

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provided by FPs.3

Currently, the Portuguese health care system is characterized by two coexisting systems: the








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



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 health care system. 11





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.











attended simultaneously by FPs and Pediatricians, a confidence interval (CI) of 95% and a



Pediatricians, at a national level. We considered that the number of delivered questionnaires

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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





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.





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.




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-


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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








Statistical methods






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.



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






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).


Total

n= 697

FP group

n= 213

FP/Pediatrici

an group

n= 484

p-

value


Mean ± SD

34.48 ± 5.73

33.48 ± 5.73

34.75 ± 4.46

<0.001




468 (67.4%) 226 (32.6%)

190 (89.6%) 22 (10.4%)

278 (57.7%) 204 (42.3%)

<0.001


tion

Not active

Active

94 (13.5%) 600 (86.5%)

46 (21.7%)

166 (78.3%)

48(10.0%)

434 (90.0%) <0.001


Single

Divorced/separated


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


Mean ± SD

36.27 ± 6.04

36.27 ± 6.04

36.84 ± 4.91

0.109




556 (80.9%) 131 (19.1%)

194 (94.6%)

11 (5.4%)

362 (75.1%) 120 (24.9%)

<0.001


Not active

Active

52 (7.6%)

634 (92.4%)

27 (13.2%)

177 (86.8%)

25 (5.2%)

457 (94.8%)

<0.001


Single

Divorced/separated


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


≤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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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).



OR

95% CI for OR





1

2.11

—

1.27 – 3.52

Mother’s professional situation

Not active

Active

1

1.90

—

0.98 – 3.70




1

2.14

—

0.64 – 7.19


Not active

Active

1

1.97

—

0.86 – 4.55


≤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%)


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


Mean ± SD

1.83 ± 0.77

1.83 ± 0.78

1.57 ± 0.66

<0.001


Mean ± SD

51.41 ± 18.64

52.41± 18.67

45.44 ± 20.19

<0.001

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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.










the:



4.11 ± 0.87* ------ (a)

2.91 ± 1.10* ------

(a)


3.85 ± 0.87*

4.11 ± 0.87* 2.38 ± 1.10* 4.29 ± 0.77*


Discussion




p<0.001 p<0.001 p<0.001 p<0.001

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the FP.













though approximately 70% of our sample simultaneously attended a Pediatrician, which can



a lower clinical knowledge mean than the Pediatrician. However, Family Physicians and Pedia-

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in health care promotion and education that is provided to parents and the general population.




Footnotes


study and all the parents who kindly answered the questionnaire.



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.


and Vasco Duarte contributed to the questionnaire validation and data collection. SR and FM




Contributorship Statement: All authors completed the ICMJE uniform disclosure form at








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References






5. Barros P, Machado S, Simões J. Portugal: Health system review. Health Sys-tems in Transition, 2011, 13(4):1–156.



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.







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:


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210x297mm (300 x 300 DPI)

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1

STROBE Statement

Item

No Recommendation





Introduction





Methods


design)









first paragraph)

Data sources/

measurement








second paragraph)













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Results






Descriptive

data






results









Discussion


second paragraphs)



limitations)




practice)



Other information


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Authors:


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Index


ABSTRACT........................................................................................................................................................................5

INTRODUCTION.............................................................................................................................................................6

OBJECTIVES.....................................................................................................................................................................7

POPULATION...................................................................................................................................................................7

SAMPLE..............................................................................................................................................................................7


PARTICIPANTS...............................................................................................................................................................8

VARIABLES....................................................................................................................................................................10

METHODS........................................................................................................................................................................12




STUDY TIMELINE:......................................................................................................................................................14


AUTHORS........................................................................................................................................................................15

REFERENCES.................................................................................................................................................................15




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OR – Odds Ratio



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ABSTRACT




by Pediatricians.



Pediatrician.











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INTRODUCTION





























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OBJECTIVES





• Parents´ age





• Household size


• Child’s age

















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to participate.

Sample size














Inclusion criteria




Exclusion criteria




last year.


the last two years.


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VARIABLES





nominal

FP group




level


Ordinal




situation


nominal

Not active

Active

Mother´s marital

status


Categorical

nominal

Single



Widower



level


Ordinal




situation


nominal

Not active

Active

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Father´s marital

status


Categorical

nominal

Single



Widower



Ordinal

≤500€

501 to 999€

1000 to 1999€

≥2000€

Private health

insurance


health insurance

Categorical Yes

No





Ordinal

1-5

Pediatrician’s

knowledge


Pediatrician.

Categorical

Ordinal

1-5


Ordinal

1-5

Pediatrician’s

accessibility


Ordinal

1-5

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METHODS

Study location





Study design








2016.








Pilot study







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values <0,1.







:

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STUDY TIMELINE:



2015 2016






Pilot study




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Cost (€)





Total cost - 920

AUTHORS


REFERENCES



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consultations.










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2. Marital Status:

Single



Widow



4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


Active

Unemployed

Retired

Student


6. Marital Status:

Single



Widower



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4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


Active Unemployed

Retired

Student

Household




499 euros or less



2000 euros or more



Yes No


_____/______/__________

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Yes No


Less than a month


15 mouths 18 months


Others


Yes No

a. If so, where?


Less than a month


15 mouths 18 months


Others


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2 - Disagree

3 - Indifferent

4 - Agree

5 - Strongly agree

1 2 3 4 5








Quiz

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2 - Disagree

3 - Indifferent

4 - Agree

5 - Strongly agree

1 2 3 4 5










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Physicians and Paediatricians? A cross-sectional study in

Portugal.

Journal: BMJ Open



Date Submitted by the Author: 14-Nov-2017





Keywords: Paediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice


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and Paediatricians? A cross-sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João Firmino-Machado6


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.


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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.


(Portugal).



MAIN OUTCOME MEASURES: Proportion of children attending the FP or FP/Paediatrician

for their surveillance appointments; association between the chosen Physician and



private health insurance); assess the parents' perception of clinical knowledge and accessibility,

regarding the Family Physician and the Paediatrician.


and 69.4% attended both the FP and the Paediatrician. Using a multivariable-binary logistic


95% CI 1.27–3.52), household net income higher than 2,000 euros (OR=5.17, 95% CI 1.02–



associated with attending both the FP and the Paediatrician; parents of children who attended



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


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- To our knowledge, this was the first study addressing the factors associated with parents’

choice in the medical care of their children;


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



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


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








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.


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


Paediatrics in secondary care.

In the Portuguese NHS, Paediatricians work in secondary care, and although they are also



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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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 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




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


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attended simultaneously by FPs and Paediatricians, a confidence interval (CI) of 95% and a



Paediatricians, at a national level. We considered that the number of delivered questionnaires


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.


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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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-




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




We included 13 socio-demographic and household variables in the analyses: parents’ age,


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



Paediatrician (FP/Paediatrician group).



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


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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


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


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


Mean ± SD

34.48 ± 5.73

33.48 ± 5.73

34.75 ± 4.46

<0.001




468 (67.4%) 226 (32.6%)

190 (89.6%) 22 (10.4%)

278 (57.7%) 204 (42.3%)

<0.001


tion

Not active

Active

94 (13.5%) 600 (86.5%)

46 (21.7%)

166 (78.3%)

48(10.0%)

434 (90.0%) <0.001


Single

Divorced/separated


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


Mean ± SD

36.27 ± 6.04

36.27 ± 6.04

36.84 ± 4.91

0.109




556 (80.9%) 131 (19.1%)

194 (94.6%)

11 (5.4%)

362 (75.1%) 120 (24.9%)

<0.001


Not active

Active

52 (7.6%)

634 (92.4%)

27 (13.2%)

177 (86.8%)

25 (5.2%)

457 (94.8%) <0.001


Single

Divorced/separated


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


≤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.


OR

95% CI for OR





1

2.11

—

1.27 – 3.52 Mother’s professional situation

Not active

Active

1

1.90

—

0.98 – 3.70 Father’s 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%)


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


Mean ± SD

1.83 ± 0.77

1.83 ± 0.78

1.57 ± 0.66

<0.001


Mean ± SD

51.41 ± 18.64

52.41± 18.67

45.44 ± 20.19

<0.001

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≤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.


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.



the:

Family Physician Paediatrician Family Physician Paediatrician


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.



and the Paediatrician. Variables with higher impact in the parents’ choice were household net





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.


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.



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though approximately 70% of our sample simultaneously attended a Paediatrician. This can


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.


neously by a Paediatrician and an FP is associated with health benefits and higher public health


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.




read and approved the final manuscript. All authors had full access to all data (including statisti-


the accuracy of the data analysis. SVR and JOL equally contributed to this article.


and Vasco Duarte contributed both to questionnaire validation and data collection. SR and FM






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licão, in the context of the programme “Aproximar”, as required by national legislation.






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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 Amer-ican Board of Family Medicine 2012; 25 (2): 139-140.

3. Makaroff LA, Xierali IM, Petterson SM, Shipman SA, Puffer JC, Bazemore AW. Fac-tors 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. Europe-an Parliament. Luxemburg, 1998.

5. Barros P, Machado S, Simões J. Portugal: Health system review. Health Systems in Transition, 2011, 13(4):1–156.

6. Direção Geral de Saúde. Programa Nacional de Saúde Infantil e Juvenil. Portugal, Lis-bon. Direção Geral de Saúde 2013; 10/2013: 9-11


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. Andersen R. Revisiting the behavioral model and access to medical care: does it mat-ter? J Health Soc Behav. 1995 Mar;36(1):1–10.

13. Andersen R, Davidson P. Improving access to care in America: individual and contex-tual indicators. In: Andersen RM, Rice TH, Kominski EF, editors. Changing the U.S. health care system: key issues in health services, policy, and management. San Francis-co, CA: Jossey-Bass; 2001. pp. 3–30.

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).





Figure Legends:


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210x297mm (300 x 300 DPI)

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STROBE Statement

Item

No Recommendation





Introduction





Methods


design)









first paragraph)

Data sources/

measurement








second paragraph)













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Results






Descriptive

data






results









Discussion


second paragraphs)



limitations)




practice)



Other information


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Authors:


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Index


ABSTRACT........................................................................................................................................................................5

INTRODUCTION.............................................................................................................................................................6

OBJECTIVES.....................................................................................................................................................................7

POPULATION...................................................................................................................................................................7

SAMPLE..............................................................................................................................................................................7


PARTICIPANTS...............................................................................................................................................................8

VARIABLES....................................................................................................................................................................10

METHODS........................................................................................................................................................................12




STUDY TIMELINE:......................................................................................................................................................14


AUTHORS........................................................................................................................................................................15

REFERENCES.................................................................................................................................................................15




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OR – Odds Ratio



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ABSTRACT




by Pediatricians.



Pediatrician.











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INTRODUCTION





























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OBJECTIVES





• Parents´ age





• Household size


• Child’s age

















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to participate.

Sample size














Inclusion criteria




Exclusion criteria




last year.


the last two years.


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10

VARIABLES





nominal

FP group




level


Ordinal




situation


nominal

Not active

Active

Mother´s marital

status


Categorical

nominal

Single



Widower



level


Ordinal




situation


nominal

Not active

Active

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Father´s marital

status


Categorical

nominal

Single



Widower



Ordinal

≤500€

501 to 999€

1000 to 1999€

≥2000€

Private health

insurance


health insurance

Categorical Yes

No





Ordinal

1-5

Pediatrician’s

knowledge


Pediatrician.

Categorical

Ordinal

1-5


Ordinal

1-5

Pediatrician’s

accessibility


Ordinal

1-5

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METHODS

Study location





Study design








2016.








Pilot study







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values <0,1.







:

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STUDY TIMELINE:



2015 2016






Pilot study




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Cost (€)





Total cost - 920

AUTHORS


REFERENCES



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consultations.










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2. Marital Status:

Single



Widow



4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


Active

Unemployed

Retired

Student


6. Marital Status:

Single



Widower



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4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


Active Unemployed

Retired

Student

Household




499 euros or less



2000 euros or more



Yes No


_____/______/__________

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Yes No


Less than a month


15 mouths 18 months


Others


Yes No

a. If so, where?


Less than a month


15 mouths 18 months


Others


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2 - Disagree

3 - Indifferent

4 - Agree

5 - Strongly agree

1 2 3 4 5








Quiz

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2 - Disagree

3 - Indifferent

4 - Agree

5 - Strongly agree

1 2 3 4 5










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Physicians and Paediatricians? A cross-sectional study in

Portugal.

Journal: BMJ Open



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




Keywords: Paediatric Assistant, Family Physician, Infant, Preschool Child, Primary Health Care, Family Practice


BMJ Open on F


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1


and Paediatricians? A cross-sectional study in Portugal. Susana Rebelo1, Sofia Velho Rua2, Joana d’Orey Leça3, Ana Couto4, Rute Teixeira5, João Firmino-Machado6


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.


(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


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.


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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- To our knowledge, this was the first study addressing the factors associated with parents’

choice in the medical care of their children;


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



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



insurance. People can also have access to private care without any insurance, paying the total

costs of the care provided. 4-5


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.


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


Paediatrics in secondary care.

In the Portuguese NHS, Paediatricians work in secondary care, and although they are also



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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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 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.


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


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attended simultaneously by FPs and Paediatricians, a confidence interval (CI) of 95% and a



Paediatricians, at a national level. We considered that the number of delivered questionnaires


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.


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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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-




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




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


Paediatrician (FP/Paediatrician group).



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


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


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


Mean ± SD

34.48 ± 5.73

33.48 ± 5.73

34.75 ± 4.46

<0.001




468 (67.4%) 226 (32.6%)

190 (89.6%) 22 (10.4%)

278 (57.7%) 204 (42.3%)

<0.001


tion

Not active

Active

94 (13.5%) 600 (86.5%)

46 (21.7%)

166 (78.3%)

48(10.0%)

434 (90.0%) <0.001


Single

Divorced/separated


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


Mean ± SD

36.27 ± 6.04

36.27 ± 6.04

36.84 ± 4.91

0.109




556 (80.9%) 131 (19.1%)

194 (94.6%)

11 (5.4%)

362 (75.1%) 120 (24.9%)

<0.001


Not active

Active

52 (7.6%)

634 (92.4%)

27 (13.2%)

177 (86.8%)

25 (5.2%)

457 (94.8%) <0.001


Single

Divorced/separated


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


≤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.


PR

95% CI for PR





1

1.15

—

1.00 – 1.33 Mother’s professional situation

Not active

Active

1

1.24

—

0.99 – 1.54 Father’s 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%)


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


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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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.


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.



the:

Family Physician Paediatrician Family Physician Paediatrician


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.


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.


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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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.


neously by a Paediatrician and an FP is associated with health benefits and higher public health


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



read and approve the final manuscript. All authors had full access to all data (including statisti-


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.




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licão, in the context of the programme “Aproximar”, as required by national legislation.






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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 Amer-ican Board of Family Medicine 2012; 25 (2): 139-140.

3. Makaroff LA, Xierali IM, Petterson SM, Shipman SA, Puffer JC, Bazemore AW. Fac-tors 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. Europe-an Parliament. Luxemburg, 1998.

5. Barros P, Machado S, Simões J. Portugal: Health system review. Health Systems in Transition, 2011, 13(4):1–156.

6. Direção Geral de Saúde. Programa Nacional de Saúde Infantil e Juvenil. Portugal, Lis-bon. Direção Geral de Saúde 2013; 10/2013: 9-11


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. Andersen R. Revisiting the behavioral model and access to medical care: does it mat-ter? J Health Soc Behav. 1995 Mar;36(1):1–10.

13. Andersen R, Davidson P. Improving access to care in America: individual and contex-tual indicators. In: Andersen RM, Rice TH, Kominski EF, editors. Changing the U.S. health care system: key issues in health services, policy, and management. San Francis-co, CA: Jossey-Bass; 2001. pp. 3–30.

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).





Figure Legends:


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210x297mm (300 x 300 DPI)

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Authors:


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Index


ABSTRACT........................................................................................................................................................................5

INTRODUCTION.............................................................................................................................................................6

OBJECTIVES.....................................................................................................................................................................7

POPULATION...................................................................................................................................................................7

SAMPLE..............................................................................................................................................................................7


PARTICIPANTS...............................................................................................................................................................8

VARIABLES....................................................................................................................................................................10

METHODS........................................................................................................................................................................12




STUDY TIMELINE:......................................................................................................................................................14


AUTHORS........................................................................................................................................................................15

REFERENCES.................................................................................................................................................................15




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OR – Odds Ratio



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ABSTRACT




by Pediatricians.



Pediatrician.











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INTRODUCTION





























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OBJECTIVES





• Parents´ age





• Household size


• Child’s age

















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to participate.

Sample size














Inclusion criteria




Exclusion criteria




last year.


the last two years.


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VARIABLES





nominal

FP group




level


Ordinal




situation


nominal

Not active

Active

Mother´s marital

status


Categorical

nominal

Single



Widower



level


Ordinal




situation


nominal

Not active

Active

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Father´s marital

status


Categorical

nominal

Single



Widower



Ordinal

≤500€

501 to 999€

1000 to 1999€

≥2000€

Private health

insurance


health insurance

Categorical Yes

No





Ordinal

1-5

Pediatrician’s

knowledge


Pediatrician.

Categorical

Ordinal

1-5


Ordinal

1-5

Pediatrician’s

accessibility


Ordinal

1-5

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METHODS

Study location





Study design








2016.








Pilot study







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values <0,1.







:

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STUDY TIMELINE:



2015 2016






Pilot study




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Cost (€)





Total cost - 920

AUTHORS


REFERENCES



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consultations.










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2. Marital Status:

Single



Widow



4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


Active

Unemployed

Retired

Student


6. Marital Status:

Single



Widower



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4th grade

6th grade

9th grade

12th grade

Higher education

Another. Which? _________________________________


Active Unemployed

Retired

Student

Household




499 euros or less



2000 euros or more



Yes No


_____/______/__________

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Yes No


Less than a month


15 mouths 18 months


Others


Yes No

a. If so, where?


Less than a month


15 mouths 18 months


Others


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2 - Disagree

3 - Indifferent

4 - Agree

5 - Strongly agree

1 2 3 4 5








Quiz

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2 - Disagree

3 - Indifferent

4 - Agree

5 - Strongly agree

1 2 3 4 5










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STROBE Statement

Item

No Recommendation





Introduction





Methods


design)









first paragraph)

Data sources/

measurement








second paragraph)













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Results






Descriptive

data






results









Discussion


second paragraphs)



limitations)




practice)



Other information


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