Lemoine.
qxd 1/13/2006 2:58 PM Page 25
ORIGINAL ARTICLE
Paediatric primary care quality and accessibility:
Parents’ perspective
Marie-Hélène Lemoine MD, Claude Lemoine MD, Claude Cyr MD
M-H Lemoine, C Lemoine, C Cyr. Paediatric primary care
quality and accessibility: Parents’ perspective. Paediatr Child
Health 2006;11(1):25-28.
OBJECTIVE: To measure parents’ satisfaction with paediatric pri-
mary care quality and accessibility.
BACKGROUND: High-quality paediatric primary care is a corner-
stone of efforts to improve health outcomes and access to care, as well
as to control health care spending. A strong primary care infrastruc-
ture is related to improved health outcomes, including an improved
mortality rate.
METHODS: A cross-sectional survey using the Parents’ Perception of
Primary Care questionnaire and evidence-based items from the Rourke
Baby Record were used to measure parents’ satisfaction.
RESULTS: Of 200 questionnaires sent, 130 were returned. The
mean number of children per family was 1.7±0.8 (mean ± SD). Sixty-
six per cent of children received their primary care from general prac-
titioners, 19% received their primary care from paediatricians, and
15% had no regular physician and identified other professionals
(community nurses, midwives or chiropractors) as their primary care
providers. Parents were questioned about their child’s hearing in 66%
of cases. Only 41% of parents received guidance about breastfeeding,
37% about adequate sleeping position, 17% about the dangers of
second-hand smoke and 16% about car safety seats. The level of sat-
isfaction with communication, contextual knowledge and coordina-
tion of care was higher for families followed by general practitioners
and paediatricians than for families followed by nonphysicians.
According to the Parents’ Perception of Primary Care scores, the over-
all satisfaction with primary care was higher for care given by general
practitioners and paediatricians than for care given by midwives or
chiropractors, and intermediate when given by nurses.
CONCLUSION: In this survey, the majority of children received
their primary care from physicians, most commonly general practi-
tioners. Parents’ overall satisfaction regarding their infant’s primary
health care was higher when it was delivered by physicians than by
alternative health care providers. Evidence-based guidance recom-
mendations were rarely followed.
Key Words: Accessibility; Paediatric primary care; Parents’
satisfaction; Quality of care
igh-quality paediatric primary care is one of the corner-
H stones of the health system that are needed to improve
health outcomes, control health care spending and improve
access to care (1). A strong primary care infrastructure is asso-
ciated with improved health outcomes, including a decrease in
the mortality rate (2). According to the Institute of Medicine
(3), primary care is “the provision of integrated, accessible
health care services by clinicians who are accountable for
addressing a large majority of personal health care needs,
developing a sustained partnership with patients and practic-
ing in the context of family and community”. Definitions of
Centre hospitalier universitaire de Sherbrooke, Département de pédiatrie, Université de Sherbrooke, Sherbrooke, Québec
Correspondence: Dr Marie-Hélène Lemoine, 2750, boulevard Laframboise, Saint-Hyacinthe, Québec J2S 4Y8. Telephone 450-261-0667,
e-mail mhlemoine@hotmail.com
Paediatr Child Health Vol 11 No 1 January 2006
La qualité et l’accessibilité des soins de
première ligne en pédiatrie : La perspective
des parents
OBJECTIF : Mesurer la satisfaction des parents envers la qualité et
l’accessibilité des soins de première ligne en pédiatrie.
HISTORIQUE : Des soins pédiatriques de première ligne de qualité
représentent la pierre angulaire des efforts en vue d’améliorer les résultats
pour la santé et l’accès aux soins ainsi que de contrôler les dépenses en
santé. Une solide infrastructure de première ligne est reliée à de meilleurs
résultats pour la santé, y compris une diminution du taux de mortalité.
MÉTHODOLOGIE : Une enquête transversale au moyen du
questionnaire sur la perception qu’ont les parents des soins de première
ligne et au moyen d’éléments probants tirés du relevé postnatal Rourke a
été entreprise pour mesurer la satisfaction des parents.
RÉSULTATS : Des 200 questionnaires envoyés, 130 ont été retournés.
Le nombre moyen d’enfants par famille était de 1,7±0,8 (moyenne ± ÉT).
Soixante-six pour cent des enfants ont reçu leurs soins de première ligne
d’omnipraticiens, 19 %, de pédiatres, et 15 % n’avaient pas de médecin
traitant et ont nommé d’autres professionnels (infirmières de santé
publique, sages-femmes ou chiropraticiens) comme dispensateurs de soins
de première ligne. Les parents ont été interrogés sur l’acuité auditive de
leur enfant dans 66 % des cas. Seulement 41 % ont reçu des conseils sur
l’allaitement, 37 % sur la bonne position de sommeil, 17 % sur les dangers
de la fumée secondaire et 16 % sur les sièges d’auto pour bébés. Le taux de
satisfaction à l’égard des communications, des connaissances
contextuelles et de la coordination des soins était supérieur dans les
familles suivies par des omnipraticiens et des pédiatres que dans celles
suivies par des non-médecins. D’après les indices de perception qu’ont les
parents des soins de première ligne, la satisfaction globale envers ces soins
était plus élevée lorsqu’ils étaient prodigués par des omnipraticiens et des
pédiatres que lorsqu’ils l’étaient par des sages-femmes ou des
chiropraticiens, et cette satisfaction était moyenne lorsque les soins
étaient assurés par des infirmières.
CONCLUSION : D’après cette enquête, la majorité des enfants ont reçu
leurs soins de première ligne de médecins, et surtout d’omnipraticiens. La
satisfaction globale des parents à l’égard des soins de première ligne de
leur nourrisson était plus élevée lorsque ces soins étaient prodigués par des
médecins que lorsqu’ils l’étaient par d’autres dispensateurs de soins. Les
recommandations probantes étaient rarement respectées.
these concepts may vary among researchers; nevertheless, all
agree that primary care must be accessible, comprehensive,
contextual (based on a provider’s accumulated knowledge of
the patient and his or her family), based on adequate commu-
nication, longitudinally continuous and coordinated.
In Canada, even though many changes in the health
care system have occurred over the past few decades, preoc-
cupation with the quality and accessibility of primary
health care for children is a more recent development. To
our knowledge, there have been no published studies that
have developed reliable and valid health indicators for
©2006 Pulsus Group Inc. All rights reserved 25
Lemoine.qxd 1/13/2006 2:58 PM Page 26
Lemoine et al
TABLE 1
Parents’ Perception of Primary Care items
Longitudinal continuity
1. If there is one particular place that you take your child for almost all of
his or her health care, how long has this been your child’s place for
health care?
2. If there is one particular person who you think of as your child’s regular
doctor or nurse, how long has this person been your child’s doctor or
nurse?
Access
3. Is it easy for you to travel to the doctor?
4. Can you see the doctor as soon as you want for routine care
(eg, checkups and physical examinations) for your child?
5. If your child is sick, can you see the doctor within one day?
6. Can you get help or advice on evenings or weekends?
Contextual knowledge
7. Do you feel the doctor knows your child’s medical history?
8. Do you feel the doctor knows your concerns about your child?
9. Do you feel the doctor knows your values and beliefs about health?
10. Do you feel the doctor knows your child overall?
Communication
11. Do you feel comfortable asking the doctor questions?
12. Does the doctor explain things to your satisfaction?
13. Does the doctor spend enough time with you and your child?
14. Does the doctor listen to you?
Comprehensiveness
15. Can the doctor take care of almost any problem your child may have?
16. Does the doctor talk to you about keeping your child healthy?
17. Does the doctor talk to you about safety (eg, car safety seats,
seat belts, bike helmets and accidents)?
18. Does the doctor talk to you about your child’s growth?
19. Does the doctor talk to you about your child’s behaviour in general
(eg, having friends and showing citizenship at school)?
Coordination
20. When necessary, can the doctor arrange for other health care for your
child?
21. When necessary, do you feel that the doctor follows up on visits to
other health care providers?
22. Do you feel the doctor communicates with other health providers about
your child, when necessary?
23. When necessary, do the doctor and school work together for your
child’s health?
Reproduced from reference 4
Canadian children and youth. The current lack of indicators
and standards of care makes it difficult to determine the status
of health and health care of Canadian children, to conduct
comparative analyses to assess performance and to establish
benchmarks for the optimal level of health service delivery.
We conducted the present cross-sectional study using a
survey to assess parents’ degree of satisfaction with paediatric
primary care quality and accessibility, and to assess the compli-
ance by health care providers with evidence-based guidelines.
METHODS
Instruments
Parental satisfaction: The Parents’ Perception of Primary
Care (P3C) questionnaire (4) was the instrument selected
to measure parental satisfaction and was translated into
26
French. It is based on the above-mentioned Institute of
Medicine definition of primary care. The P3C question-
naire was designed to measure six components of care that,
when present, constitute high-quality primary care: longitu-
dinal continuity, access, contextual knowledge, communi-
cation, comprehensiveness and coordination (Table 1).
Computing the mean of the nonmissing values on each
scale formed the total score, as well as the score for each
subscale. Scores ranged from 0 to 100, with high scores
reflecting care conforming to this a priori definition. The
P3C questionnaire is a practical, reliable and valid measure
of parents’ satisfaction with paediatric primary care (4). It
can be used alone or in conjunction with other measures to
enhance outcomes and evaluate the impact of system
changes on delivery of the main elements of primary care.
Evidence-based guidelines: The present study used the
Rourke Baby Record (5), an evidence-based system of well-
infant and -child health maintenance that was revised and
updated in 2000 and was promoted by the Canadian Paediatric
Society (5) and the College of Family Physicians of Canada.
Only the following seven evidence-based elements were
included, these being the most representative of a good well-
baby visit: guidance about breastfeeding, car safety seats, safe
sleeping position, immunization and the danger of second-
hand smoke; hearing inquiry; and examination of the hips.
The survey was sent to a randomly selected sample of
200 parents who had a newborn at the Centre hospitalier
universitaire de Sherbooke (Sherbrooke, Quebec), a terti-
ary care centre, between January 1, 2002, and June 30,
2002. Children were between six and 12 months of age at
the time of the study. Parents had to return the survey in a
postage-paid envelope, but no reminder notices were sent
to nonresponders.
Data analysis
Continuous variables are presented as mean ± SD. Ratios
were compared using the χ2 test. Mean values were tested
using the Student’s t test for continuous and normally dis-
tributed variables. P<0.05 was considered to be statistically
significant.
RESULTS
Patient characteristics
Of 200 questionnaires sent, 130 were returned; of those,
116 were completed (response rate of 58%) and 14 were not
filled out correctly (13 wrong addresses and one English-
speaking family). Of the 116 families who responded to the
questionnaire, 66% of parents identified the main primary
care provider for their child as a family physician, 19%
identified a paediatrician, 9% identified a nurse, 2% identi-
fied a chiropractor, 2% identified a midwife and 2% identi-
fied nobody in particular. Nurses, chiropractors and
midwives represented a small number of cases and were
grouped into the ‘nonphysician’ category. The location of
primary care services was identified as a private clinic by
54% of parents, a community health clinic by 23%, a hos-
pital outpatient clinic by 17%, and a walk-in clinic or an
Paediatr Child Health Vol 11 No 1 January 2006
Lemoine.qxd 1/13/2006 2:58 PM Page 27
emergency room by 5%. The mean age of the parents was
29±4 years and 8% of the families were headed by a single
parent. The mean number of children per family was
1.7±0.8. Ten per cent of families were living in poverty
(annual income of less than $20,000), while 59% earned
more than $40,000 per year.
Compliance with evidence-based guidelines
The quality of paediatric primary care was assessed at two,
four and six months using the Rourke Baby Record.
According to parental recall, 40% of parents received
advice about breastfeeding from their primary care provider
at two months compared with 30% at four months and 22%
at six months. Fourteen per cent of parents recalled receiv-
ing guidance about car safety seats at two months, while 9%
remembered receiving it at four months and 9% at six
months. Parents received guidance about sleeping position
in 87% of cases at birth, 37% at two months, 22% at four
months and 19% at six months. Primary care providers dis-
cussed the dangers of second-hand smoke in 17% of cases at
two months and in 12% each at four months and six months.
Sixty-one per cent of parents remembered being asked about
their child’s hearing at two months, 58% at four months and
53% at six months. According to parents, 81% of children
had their hips examined at two months, 74% at four months
and 69% at six months. Finally, 94% discussed immunization
with their primary care provider at two months, 91% at four
months and 88% at six months (Figure 1).
Breastfeeding was discussed by family physicians in 41% of
children compared with 36% of children followed by paedia-
tricians and 47% by nonphysicians. None of the families with
the lowest annual income remembered discussing breastfeed-
ing with their primary care provider. Guidance about breast-
feeding was given more often to higher income families than
to lower income ones (46% versus 0%; P=0.01). Guidance
about car safety seats was provided at least once by family
physicians in 16% of children, by paediatricians in 14% and
by nonphysicians in 24%. Sleeping in the supine position was
encouraged at least once by family physicians in 32% of chil-
dren, in 36% of children followed by paediatricians and in
59% of children followed by nonphysicians. Family physicians
and nonphysicians inquired about hearing at least once in
65% of children compared with 68% of children followed by
paediatricians. Guidance about the dangers of second-hand
smoke was given more frequently by nonphysicians than by
family physicians (47% versus 13%; P=0.007). It was given to
16% of children followed by paediatricians, with no signifi-
cant difference. Hips were examined in 90% of children fol-
lowed by family physicians, in 100% of children followed by
paediatricians and in 82% of those followed by nonphysicians.
Finally, immunization was discussed by family physicians and
paediatricians in 95% of children, and by the nonphysicians
in 88% of them.
Children followed by nonphysicians had more visits
than children in the two other groups (10 visits with non-
physicians versus seven with family physicians and six with
paediatricians).
Paediatr Child Health Vol 11 No 1 January 2006
Paediatric primary care quality and accessibility
100
90 2 months 4 months 6 months
80
70
60
% 50
40
30
20
10
0
Breastfeeding Car safety Sleeping Second-hand Hearing Hips Immunization
seats position smoke
Rourke Baby Record
Figure 1) Compliance with evidence-based guidelines
Children were classified into acceptable and perfect
follow-up categories. To be considered an acceptable
follow-up, guidance about breastfeeding, car safety seats,
sleeping position and the harms of second-hand smoke;
inquiry about hearing; and examination of the hips had to
be done at least once between two and six months of age.
Also, immunization had to be given at two, four and six
months. Only 4% of children (five families) had an
acceptable follow-up. Six per cent of children had none of
these seven criteria performed, and 28% had three of seven
performed. To be considered a perfect follow-up, guidance
about breastfeeding, car safety seats, sleeping position and
the harms of second-hand smoke; inquiry about hearing;
and examination of the hips had to be done at birth, and
at two, four and six months. Immunization also had to be
done at two, four and six months. Only 3% of children
(three families) had a perfect follow-up.
Parents’ satisfaction with accessibility of paediatric
primary care
Parents in all three groups had problems with accessibility.
Fifty per cent could access their primary care provider easily,
whereas 40% could not see their primary care provider in a
timely manner for routine care. Fifty-eight per cent could
not see their primary care provider within one day if their
child was sick and 60% could not get help or advice on
evenings or weekends.
Parents felt that family physicians and paediatricians had a
better contextual knowledge than nonphysicians (P3C sub-
scale of 67, 70 and 39, respectively). They also felt that fam-
ily physicians and paediatricians had better communication
skills and a better comprehensiveness of the patient, and were
better at coordinating care when necessary (Figure 2).
Overall, parents’ evaluation of the provision of primary
care was better when care was provided by family physicians
(P3C score 70±21), by paediatricians (P3C score 69±17) and
by nurses (P3C score 58±24) than when it was provided by
midwives (P3C score 8±0) or chiropractors (P3C score 26±0).
DISCUSSION
In the present study population, 15% of children did not
receive primary care from physicians. Evidence-based
27
Lemoine.qxd 1/13/2006 2:58 PM Page 28
Lemoine et al
90 * P = 0.0002
P = 0.0008
P = 0.03
80 P = 0.0003
70
60
% 50
40
30
20
10
0 is to find a way to facilitate and support the application of evi-
Accessibility Contextual knowledge Communication Comprehensiveness
Family physicians Paediatricians
Figure 2) Parents’ satisfaction with paediatric primary care. *P values
calculated with Student’s t test
guidelines for paediatric primary care and guidance were
rarely followed. Compliance with evidence-based guide-
lines was not better when the primary care provider was a
physician than when it was a nonphysician. The only signif-
icant difference was the guidance about danger of second-
hand smoke that was given more often by nonphysicians
than by physicians. Even though good evidence-based
guides of well-infant and -child health maintenance, such as
the Rourke Baby Record, exist, they were not followed by
primary care providers in the present study. The majority of
children were followed by family physicians, which was
expected because paediatricians are mainly asked to provide
secondary and tertiary care. Parents whose children were fol-
lowed by family physicians and paediatricians were more sat-
isfied about the care they received than were those followed
by midwives and chiropractors. Parents’ satisfaction with the
care offered by nurses was intermediate.
Families in all three groups had problems with accessi-
bility. Parents had difficulty accessing their primary care
provider and getting an appointment in a timely matter for
routine care. When their child was ill, it was hard to see
their primary care provider within one day and to get help
or advice on evenings or weekends. Physicians’ availability,
setting and timing were all suboptimal for parents to get pri-
mary care for their child.
A recent survey done in the United States showed that
of 432 children aged four to nine months, 82% were fol-
lowed by paediatricians. In that population, nearly all par-
ents had discussed immunization issues with their primary
care provider, while approximately 90% of them had dis-
cussed breastfeeding and adequate sleeping position.
Guidance about car safety seats was provided for 86% of
parents (6). Also, 77% of paediatricians had discussed the
dangers of second-hand smoke with parents (7). Finally, the
global satisfaction rating of parents was 86.5% (8).
Satisfaction was higher for children in excellent or very
good health and for those where the duration of the visit
was longer than 10 min. Satisfaction was the lowest for
Hispanic children, for those who received their care in a
community health centre or a hospital clinic, and for those
who had missed or delayed care (8).
28
P = 0.002 Immunization issues were discussed as often in the pres-
P = 0.004
P = 0.005
ent study as in the American survey (7). Guidance about
P = 0.004
breastfeeding, adequate sleeping position, car safety seats
and the dangers of second-hand smoke was given less fre-
quently in our population than in the population in the
American study. Satisfaction with primary care was similar
between the two populations.
Primary care providers need to use already existing and
easily available tools, such as the Rourke Baby Record, to
improve the quality of paediatric primary care. The challenge
Coordination
Nonphysicians
dence-based practice and policies.
Finally, there are limitations to the present study. The
cohort was small and originated from a small geographical
area, which limits the generalizability of the study results.
Also, there may have been a response bias: parents who were
less satisfied about the care they received or those who had a
bad experience may have been more prone to complete the
questionnaire to manifest their displeasure. Finally, there was
probably a recall bias. Parents may not have remembered six
months later everything that was said or done at the time of
their visit with their primary care provider. On the other
hand, because five of the seven criteria of the Rourke Baby
Record are related to guidance, we believe that if parents did
not remember the guidance provided, the goal of the
encounter was not achieved. The health care providers may
have given more accurate data.
CONCLUSION
Because the maintenance of good health starts with pre-
vention, paediatric primary care should be a priority of
Canada’s health care system. Parents were more satisfied
with the primary health care of their infants when it was
delivered by physicians than by alternative health care
providers. Evidence-based guidelines were rarely followed
by health care providers in the study population. Studies
and strategies need to be identified to improve the quality
and accessibility of primary care for children.
REFERENCES
1. Starfield B, Simpson L. Primary care as part of US health services
reform. JAMA 1993;269:3136-9.
2. Starfield B. U.S. child health: What’s amiss, and what should be done
about it? Health Aff (Millwood) 2004;23:165-70.
3. Donaldson M, Yordy K, Lohr K, Vanselow N, eds. Primary Care:
America’s Health in a New Era. Washington: National Academy Press,
1996.
4. Seid M, Varni JW, Bermudez LO, et al. Parents’ Perceptions of
Primary Care: Measuring parents’ experiences of pediatric primary
care quality. Pediatrics 2001;108:264-70.
5. Rourke J, Rourke L, Leduc D. Rourke Baby Record: Evidence-Based
Infant/Child Health Maintenance Guide I. <http://www.cps.ca/english/
statements/CP/Rourke/RourkeBabyRecord.htm> (Version current at
January 11, 2006).
6. Olson LM, Inkelas M, Halfon N, Schuster MA, O’Connor KG,
Mistry R. Overview of the content of health supervision for young
children: Reports from parents and pediatricians. Pediatrics
2004;113(6 Suppl):1907-16.
7. Kogan MD, Schuster MA, Yu SM, et al. Routine assessment of family
and community health risks: Parent views and what they receive.
Pediatrics 2004;113(6 Suppl):1934-43. (Erratum in 2005;116:802)
8. Halfon N, Inkelas M, Mistry R, Olson LM. Satisfaction with health
care for young children. Pediatrics 2004;113(6 Suppl):1965-72.
Paediatr Child Health Vol 11 No 1 January 2006