Dr. Soha Rashed

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Preschool Health Services Indicators of quality
of Under-five Health Services

• Presented by
• Dr. Soha Rashed
• Professor of Community Medicine
• Faculty of Medicine - Alexandria University
• 2011-2012

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Preschool Health Services

• Preschool children are those aged one to less
  than six years.
• In most countries, there is a relative neglect of
  children of preschool age, where the schedule of
  work in MCH centers provides only one day per
  week for preschool children.

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 Characteristics of preschool period

• High morbidity of infectious and parasitic
  diseases
• High prevalence of malnutrition
• High incidence of injuries
• High mortality  
• Growth and development

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1. High morbidity of infectious and parasitic
diseases 

• Infectious Diseases
• Respiratory e.g., ARI, Chicken Pox, Whooping
  Cough, German Measles, etc.
• GIT e.g., Diarrheal Diseases, Enterica ,
  Hepatitis A.
• Skin Diseases e.g., Impetigo, Scabies and
  Fungal Diseases.
• Parasitic infections e.g., Oxyuris and Ascaris.

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2. High prevalence of malnutrition

• Malnutrition is prevalent among preschool
  children due to
•  
• Hyperactivity and lack of interest in food.
• Faulty feeding habits.
• High prevalence of infectious and parasitic
  diseases .

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The most common malnutrition diseases among
preschool children are

• Protein energy malnutrition (mild, moderate and
  severe)
• Micronutrient deficiencies iron deficiency
  anemia, vitamin A deficiency and iodine
  deficiency.
• Rickets.

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• Malnutrition in early life affects the physical
  growth, and is considered a risk factor for
  mortality from infectious diseases.
• Severe prolonged malnutrition in the first two
  years of life is associated with retarded brain
  growth and mental development, which persists to
  adult life.

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3. High incidence of injuries

• Preschool children are more prone to injuries as
  they are curious, energetic and eager to explore
  the environment.
• Most injuries occur where children spend the most
  active portion of their day (home, nursery or
  playgrounds).
• Falling downstairs causing head injuries or
  fractures.
• Household liquids Ingestion (kerosene, potash ,
  insecticides).
• Ingestion of drugs.
• Burns or scalds.
• Electric shock.
• Almost all injuries are preventable. Efforts to
  reduce preschool injury rate should focus on the
  promotion of safety at homes, kinder gardens and
  play grounds as regards conditions and practices.
•  

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4. High mortality

• Child Death Rate
• Under-five Mortality Rate

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5. Growth and development

• Growth
• By the end of the second year, the birth weight
  gets quadrupled. After the second year, the
  increase is steady at an annual rate of about
  2.25 - 2.75 kg in weight and 7.5 cm in height
  until the adolescent spurt occurs.
• Development
•  Motor skills are usually more coordinated in the
  second year relative to the first year. The
  behavioral development of the child must be
  assured through emotional and moral stability,
  that is, a home where he will find bonds of
  affection and discipline.

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Care of preschool children

• This is the responsibility of MCH centers (urban
  areas), and Rural Health Centers/Units (rural
  areas).
• Care of preschool children includes
• Preventive activities
• Care in illness
• Treatment of dental problems
• Nutritional education
• Health education

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I. Preventive activities

• Why important?
• Events in early life (nutritional status and
  infections) can affect health as the child is
  growing up to an adult.
• Many health problems can be prevented through
  early intervention, e.g. rheumatic heart disease
  (caused by repeated acute follicular
  tonsillitis), mental retardation (caused by
  congenital hypothyroidism).
• Certain diseases may have their roots in early
  life. e.g., Rickets, Dental caries, Deafness,
  Obesity.
• Some chronic adult orthopedic ailments are
  probably connected with development anomalies in
  young children (e.g. congenital dislocation of
  the hip).
• Thus, preventive activities are necessary to
  detect any health deviation, and provide early
  intervention.

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Periodic checkup

• During the 2nd year of life, at least four visits
  should be paid to MCH centers or RHU/RHC
• During the third to sixth years of age, two
  visits should be paid every year.

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Aims of these routine evaluations (periodic
check up) are

•  1. Assessment of the growth and development of
  the child using growth charts and developmental
  tables.
•  

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Growth charts
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• 2. Screening for detection of
• Visual defects.
• Hearing defects. Children with perceptual
  disorders particularly deafness should be
  screened as early as possible at least by the end
  of the second year.
• Speech defects.
• Orthopedic defects.
• Dental appraisal should always be part of the
  preschool program as milk teeth are important for
  the growth of permanent teeth, and for the
  general growth of the jaws.
• Laboratory investigations, the nature of which
  depends on the community problems (e.g. blood,
  urine and stool).
•  
• 3. Communicable disease prevention in Egypt,
  preschool children receive booster doses of
  Polio, DPT and MMR vaccines at the age of 18-24
  months. (Refer to EPI)

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•  II. Care in illness
• Treatment of minor diseases, and referral of
  cases needing specialized care.
• III. Treatment of dental problems
•  
• IV. Nutritional education
• It aims at initiating healthy food habits for
  mothers and children. It requires adequate time,
  facilities, finance and personnel with practical
  dietary knowledge. Demonstration kitchens should
  be present in MCH centers to instruct mothers on
  how to prepare diet for young children.
• V. Health education
• Health education areas should cover growth and
  development, children needs, communicable disease
  prevention, diet during infection, injury
  prevention, family planning, etc.

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Indicators of quality of Under-five Health
Services

1. Infant Mortality Rate
2. Neonatal Mortality Rate
3. Post neonatal Mortality Rate
4. Child Death Rate
5. Under-five Mortality Rate

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1. Infant Mortality Rate IMR

• It is an age-specific mortality rate.
• Infant mortality rate is computed using the
  following formula

IMR
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• In Egypt, Infant mortality rate is 19/1000 LB
  according to WHO (2010).
• In Malaysia IMR was 6.4/1000 LB in 2008.
• Infant deaths are related directly to poverty,
  diseases, bad sanitary conditions, overcrowding
  and ignorance.
• Infant mortality rate is a good index for
  community development in general, and of infant
  welfare services in particular, as it is a
  measure of the effect of the different
  environmental factors surrounding the infant
  during the first year of life.

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The main causes of infant mortality (ordered by
frequency) are

• ARI (acute respiratory infections bronchitis and
  bronchopneumonia).
• Gastroenteritis and dehydration.
• Low birth weight and congenital anomalies.

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Means of reducing infant mortality

• Since the etiology of infant mortality is
  multifactorial, no single intervention can reduce
  infant mortality.
• The measures needed for the reduction of infant
  mortality are classified into general measures
  and specific measures.

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I. General measures

• Improvement of socioeconomic standards and
  environmental sanitation. Since mortality of
  infants is mainly related to environmental and
  socioeconomic conditions, improvement of
  nutritional standards, provision of safe water
  and basic sanitation, improvement of housing,
  agriculture and industry are all measures that
  reduce infant mortality.
• This is why infant mortality is universally
  recognized not only as the most important
  indicator of health status of children, but also
  as an indicator of community development.

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• Education of females This can result in
• delay in the age of marriage
• prevention of early pregnancy
• increases womens awareness regarding personal
  hygiene, better utilization of health services
  and family planning services, better care of
  their children, etc.
• Studies show that high illiteracy rates are found
  among women with high infant mortaliy rate.

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II- Specific measures

• Maternal care
• Antenatal, natal and postnatal care.
• Family planning.
• Adequate maternal nutrition.
• Infant care
• Prevention of infections especially through
  immunization against the EPI targeted diseases.
• Early detection and proper management of ARI and
  gastroenteritis.
• Breast-feeding and safe weaning practices.
• Growth monitoring.
• Special care to LBW (low birth weight) babies.

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2. Neonatal Mortality Rate NMR
NMR

• Neonatal mortality rate can be divided into
• Early neonatal mortality deaths in the first
  week of life.
• Late neonatal mortality deaths from 7 to 28 days
  of life.

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The main causes of neonatal mortality are

1. Low birth weight and prematurity.
2. Congenital anomalies.
3. Asphyxia neonatorum.
4. Birth injuries e.g. head injuries.
5. Neonatal infections e.g., tetanus neonatorum,
   neonatal septicemia, neonatal meningitis,
   neonatal pneumonia and neonatal diarrhea.

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Services aiming at reducing neonatal mortality
include

1. Antenatal, natal and postnatal services.
2. Special care of LBW babies.
3. Improving quality of obstetric care to prevent
   birth injuries and asphyxia.
4. Family planning.

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3. Post neonatal Mortality Rate PNMR
PNMR

• The main causes of post neonatal mortality are
• ARI.
• Gastroenteritis and dehydration.
• Congenital anomalies and prematurity.
• Services aiming at reducing post neonatal
  mortality include
• (Same as what have been discussed in infant
  mortality rate)
• I. General measures Improvement of socioeconomic
  standards and environmental sanitation and
  education of females.
• II. Specific measures Maternal care and Infant
  care.

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4. Child Death Rate

• The child death rate is the number of deaths of
  children aged 1 4 years per 1000 children in
  the same age group in a given year and locality.
  It thus excludes infant mortality.
• The child death rate is computed by the following
  formula

In Malaysia, Child Death Rate was 0.4 per 1000
population aged 1-4 years in 2008.
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The main causes of death in children aged 1-4
years old are

1. ARI
2. Gastroenteritis and dehydration.
3. Other infections coupled with malnutrition.
4. Injuries.

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• The child death rate is a more refined indicator
  of the social situation in a country than is the
  infant mortality rate.
• It reflects the adverse environmental health
  hazards (e.g. malnutrition, poor hygiene,
  infections and injuries) including economic,
  educational and cultural characteristics of the
  family.
• In the age group 1-4 years, the second year is
  the period when the young child is at highest
  risk.

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5. Under-five Mortality Rate

• UNICEF defines this as the annual number of
  deaths of children age under-five years,
  expressed as a rate per 1000 live births.
• More specifically, it measures the probability of
  dying between birth and exactly 5 years of age.
• It is considered as the best single indicator of
  social development and well being as it reflects
  income, nutrition, health care and basic
  education, etc.
•  
• Under-five mortality rate is computed by the
  formula
•  
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• In Egypt, it is 21.8/1000 LB (2008).
• In Malaysia, it is 6/1000 LB (2011)

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The main causes of under- five mortality rate
are

1. ARI
2. neonatal and perinatal causes
3. Gastroenteritis and dehydration
4. Injuries

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