|Year : 2022 | Volume
| Issue : 7 | Page : 1021-1028
Influence of social disadvantage among children admitted to the pediatric emergency unit of a tertiary Hospital in Nigeria
E Agelebe1, SB Oseni2, OJ Adebami3, OA Oyedeji3, AO Odeyemi1
1 Department of Pediatrics, College of Health Sciences, Bowen University, Ogbomoso, Oyo-State, Nigeria
2 Department of Pediatrics and Child Health, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun-State, Nigeria
3 Department of Pediatrics and Child Health, Ladoke Akintola University of Technology, Ogbomoso, Oyo-State, Nigeria
|Date of Submission||07-Apr-2021|
|Date of Acceptance||17-May-2022|
|Date of Web Publication||20-Jul-2022|
Dr. A O Odeyemi
Department of Pediatrics, College of Health Sciences, Bowen University/Bowen University Teaching Hospital, Ogbomoso, Oyo-State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Social disadvantage has an influence on the health of individuals. In developed countries, the prevalence, pattern of social disadvantage, and the outcome of admissions in socially disadvantaged children are under-studied. Aim: To determine the prevalence of social disadvantage, pattern of diseases, and illness outcomes among socially disadvantaged children. Patients and Methods: This was a prospective hospital-based study involving 400 patients who presented at the pediatric emergency unit (PEU) of a tertiary hospital in Southwest Nigeria. Information on socio-demography and history of illness was obtained from consecutive children using a proforma. The data was analyzed using SPSS version 20. Results: The 400 participants comprised 276 male and 124 female giving a ratio of 2.2:1. Their age range was 1–14 years; the mean ± SD age was 4.6 ± 2.3. Three hundred (75%) of the children were socially disadvantaged. The social factors associated with social disadvantage were low income, unemployment of mothers, polygamous setting, single parenting, rural residence, and low registration for health insurance. There was a significant association between social disadvantage and the development of malaria (P = 0.03), pneumonia (P = 0.01), septicemia (P = 0.03), diarrhea diseases (P = 0.04), neonatal jaundice (P = 0.04), meningitis (P = 0.04), and protein-energy malnutrition (P = 0.003). Death was significantly worse among the children who are socially disadvantaged (P = 0.0001). Conclusion: Many children admitted to the PEU in Osogbo are socially disadvantaged. Children of low-income parents, unemployed mother, single parent, residents of rural places, and those without health insurance are more vulnerable to developing infectious disease as well as neonatal jaundice and protein-energy malnutrition. Socially disadvantage increases the risk of poor illness outcome (death).
Keywords: Childhood disease, disease outcome, health care utilization, socioeconomic factors
|How to cite this article:|
Agelebe E, Oseni S B, Adebami O J, Oyedeji O A, Odeyemi A O. Influence of social disadvantage among children admitted to the pediatric emergency unit of a tertiary Hospital in Nigeria. Niger J Clin Pract 2022;25:1021-8
|How to cite this URL:|
Agelebe E, Oseni S B, Adebami O J, Oyedeji O A, Odeyemi A O. Influence of social disadvantage among children admitted to the pediatric emergency unit of a tertiary Hospital in Nigeria. Niger J Clin Pract [serial online] 2022 [cited 2022 Nov 28];25:1021-8. Available from: https://www.njcponline.com/text.asp?2022/25/7/1021/351441
| Introduction|| |
Social disadvantage is an enforced lack of socially perceived necessities such as education, good housing, and access to health services among others, as well as exclusion from key activities in the society. The socially disadvantaged child is the one who is handicapped in the task of growing up to lead a competent and satisfying life. Such socially disadvantaged children may be handicapped in terms of family characteristics (single parenting, polygamous family); personal characteristics (unemployed parents, uneducated parents); or social group characteristics (low socioeconomic class of parents or ethnic or racial groupings). It also includes the children brought up by uneducated or unemployed parents and/or parents who are divorced, separated or in plural marriages; the death of a parent and early marriage. Race or ethnic group may constitute a social disadvantage.
Increasing number of studies have implicated social disadvantage on health status and morbidity. Adriaanse et al. established the link between mental health problems and social disadvantage. Their findings revealed an increasing risk of mental health problems with a degree of social disadvantage in all ethnic groups studied. This is corroborated by the findings of other studies, which found that social disadvantage has negative impacts on a neurodevelopmental milestone as well as motor and receptive language attainments, and academic performance. The study of Conwell et al. also revealed a significant association between social disadvantage and onset of risky behavior like cigarette smoking and the use of illicit drugs. Surprisingly, Baumer et al. documented that social disadvantage has no effect on diabetes prevalence.
Despite a substantial body of evidence suggesting a strong link between social disadvantage and mental health, there are insufficient data on the association between social disadvantage and pattern of pediatric emergencies. The present study evaluated the pattern of disease presentation among socially disadvantaged children, the associated socio-demographic factors, and their effect on illness outcomes. This will help in the advocacy for more social support in alleviating the adverse social conditions with the hope of improving the illness outcome in such children.
| Methodology|| |
This was a prospective, longitudinal, hospital-based study carried out in the pediatric emergency unit. The study was approved by the Research Ethics Committee (REC) of the hospital, with protocol number/REC/2013/07/11/146.
All children ill enough to be admitted and whose caregiver gave consent were recruited for the study. Assent was also obtained from subjects aged 6 years and above. Priority was given to immediate resuscitation of patients until clinically stable. History of illness was taken and appropriate physical examination was conducted. Investigations were done as necessary and indicated to arrive at diagnoses.
Diagnoses of illnesses were made according to standard recommendations. The diagnosis of malaria was confirmed based on the presence of trophozoites of Plasmodium falciparum on thick blood film smears viewed under a microscope. Clinical diagnosis of pneumonia was made when there is history of cough of less than 2 weeks duration, fever, difficult or fast breathing, chest wall in-drawing, and auscultatory findings of at least one of the followings: reduced breath sound intensity, bronchial breath sound, or crepitation. The diagnosis of pneumonia and its complications was confirmed by a chest radiograph. The diagnosis of septicemia was confirmed when blood cultures revealed the growth of microorganisms.
Management was instituted as appropriate based on the hospital's standard protocol. No patient was denied any required treatment intervention in this study. Parents or caregivers were interviewed within 24 hours of admission; information about the social status (such as occupation of parents, educational qualification and income of parents), marital status of parents, place of residence, duration of illness before presentation, and NHIS registration was recorded in a semi-structured questionnaire designed for this study. Parental education was regarded as “low” if the educational attainment was secondary school and below, while it is regarded as “high” if it is beyond secondary education (tertiary education). Each child was ascribed a social class based on average social class of either parents or surrogates as described by Ogunlesi et al.
A modified model created by Sonia et al. was used for the purpose of creating a social disadvantaged index (score). This scoring system has been validated for characterizing social disadvantage. The model makes use of the following parental parameters (such as income, marital status, and employment status) to assess the child. The average of both parents score was used to calculate the child's social disadvantage score. Each of the parameters—parental income, employment status, and marital status—was assigned a score of 2, 2, and 1, respectively. The maximum score attainable was 5, which indicated the highest social disadvantage score. Based on the score, social disadvantage was classified as: None (0), Low (1), Moderate (2-3), and High (≥4).
Anthropometric measurements such as weight, height/length, head circumference, and mid arm circumference were obtained using standard methods. The anthropometric data were used to assess their nutritional status. Measurements obtained for each child were inputted into WHO chart and this was used to obtain their classes of weight for age, height for age, and Body Mass Index (BMI) (for children aged 2 years and above) for age and gender based on WHO classification, which uses Standard Percentiles and Z-scores. Underweight and stunting malnutrition were defined as weight for age and height for age < -2 Z-scores below the median of the WHO child growth standards, respectively, while Z-scores between -2SD and +2SD for weight for age, height for age, and BMI were classified as normal weight, normal height, and healthy weight, respectively.
Data were analyzed using Statistical Package for Social Sciences (SPSS) version 20. Social disadvantage scores were grouped as being “no” for scores of 0, low for scores of 1, moderate for scores of 2–3, and high for scores >4. Means and standard deviations (SD) were determined for continuous variables such as weight, height/length while proportions and percentages were determined for categorical variables. The differences between the proportions of categorical variables were determined using Pearson's Chi-square test, while the unpaired t-test was used to evaluate the difference between the means of the socially advantaged and disadvantaged groups. A multivariate logistic regression analysis was performed to determine the determinants of social disadvantage among the significant variables. Statistical significance was established when the value of probability “P” was less than 0.05.
| Results|| |
Four hundred and thirty children were recruited for this study. Thirty (6.98%) withdrew from the study due to parental refusal to divulge information on their social status and income, thus, leaving a total of 400 children completing the study. Three hundred and forty (85%) of the subjects were aged 5 years and below, with the majority being infants. Two hundred and seventy-six (69%) were males and 124 (31%) were females giving a male to female ratio of 2.2: 1. The factors of social disadvantage identified include single parentage, unemployed parents, lack of health insurance, rural residence, and polygamous family setting [Table 1].
Degree of social disadvantage among the participants
Three hundred subjects (75%) had a social disadvantage score of ≥1 and, hence, they were socially disadvantaged, while one hundred (25%) had a score of 0 and, thus, they were not socially disadvantaged. More than one-third (35.5%) of the participants were moderately disadvantage (score of 2-3) [Figure 1].
|Figure 1: Degree of social disadvantage among the participants. *Total number of disadvantaged children = 300 (75%)|
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Social characteristics of parents/caregivers
Two hundred and forty (60%) of the fathers had their education up to tertiary level (PhD, Master's degree, Bachelor's degree, HND, OND, NCE, and Technical Education), while 196 (49%) of the mothers had their education up to tertiary level. Sixteen (4%) of the children were brought up by surrogates or other caregivers, of which twelve (75%) had primary education or no formal education and twelve (75%) were unemployed. The families of three hundred and eight (77%) subjects lived in a rented accommodation [Table 2].
Estimated monthly income of parents/caregivers
Two hundred and forty (60%) fathers earned above the Nigerian minimum wage of N 30,000, while 152 (38%) mothers earned above ₦30,000 [Table 3].
Pattern of disease diagnosed in the participants
Two hundred and eighty-three (70.6%) of the admission was attributable to infectious diseases. Malaria, pneumonia, septicemia, and diarrheal diseases accounted for 108 (27%), 43 (10.75%), 40 (10%), and 28 (7%) of the admissions, respectively. The noncommunicable diseases and surgical-related disorders accounted for 107 (26.75%) and 10 (2.5%) of the admissions, respectively [Table 4]. There was a significant association between social disadvantage and the development of malaria (P = 0.03), pneumonia (P = 0.01), septicemia (P = 0.03), diarrhea diseases (P = 0.04), neonatal jaundice (P = 0.04), meningitis (P = 0.04), and protein-energy malnutrition (P = 0.003) [Table 4].
Socioeconomic classification of the participants
Sixty-two percent of the subjects are from the lower class (class 1 and 2) and middle class (class 3), i.e., 32% and 30%, respectively. Thirty-eight children belong to the upper class (class 4 and 5) [Figure 2].
Association between social factors and social disadvantage/nonsocial disadvantage
There is a statistically significant association between low parental income, single parent families, unemployed parents, rural inhabitant, non-NHIS registration, duration of symptoms before admission, and social disadvantage in the participants (P = 0.0001, respectively) [Table 5].
|Table 5: Association between social factors and social disadvantage/nonsocial disadvantage|
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Malnutrition (underweight and stunting malnutrition) was higher among children with social disadvantage. Two hundred and eight (52%) participants were underweight while sixty-four (16%) were stunted. This relationship was statistically significant, P = 0.009 and 0.042, respectively. There was a significant association between longer duration of hospital stay (≥5 days) and being socially disadvantaged, P = 0.0001. The participants who were socially disadvantaged recorded higher mortality; this was statistically significant, P = 0.0001 [Table 6].
|Table 6: Association between nutritional status, duration of hospital stay, and illness outcome among non-sociallydisadvantaged and socially disadvantaged subjects|
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Following regression analysis of the significant factors associated with social disadvantage, only the duration of illness was a determinant of social disadvantage [Table 7].
|Table 7: Multivariate logistic regression model of factors associated with social disadvantage|
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| Discussion|| |
The present study revealed a high prevalence (75%) of socially disadvantaged children in the studied population. Although just a small fraction of the studied population was highly disadvantaged, more than a third of them were moderately disadvantaged while about a third of them were in the low disadvantaged group. This is at variance with previous documentation that reported the prevalence of 47% in the same state. This may be attributed to the poor socioeconomic development in Africa, particularly in Nigeria. Studies have shown that the economic growth of the country has been muted over years. Despite some progress in socioeconomic trends, the human capital development has remained poor with associated inequality in terms of income and opportunities and resultant adverse effect on poverty alleviation.
The distribution pattern of illness particularly the incidence of noncommunicable diseases was comparable among the socially disadvantaged and non-socially disadvantaged, while the incidences of most infectious diseases, especially malaria, pneumonia, septicemia, diarrheal diseases, meningitis, as well as neonatal jaundice and PEM were significantly higher in socially disadvantaged children when compared with their non-socially disadvantaged counterparts. Consistent with our findings, infectious diseases, especially malaria, have been linked to poor socioeconomic status.,,, There are multiple factors linking malaria and poverty; these include poor housing conditions and poor access to preventive measures such as insecticide-treated bed-nets (ITN) and household insecticide spraying. The use of these measures remains vital in the control of malaria among children of all social class; hence, the impact of social class on the development of malaria should have been minimized through the use of ITN. This study however did not visit the participants' households to confirm if ITN were in use. Relying alone on information about the use of ITN through parental/caregiver recall may not be entirely accurate. Poor nutritional status is another contributing factor that has made malaria infection more frequent among the socially disadvantaged. Sachs et al. noted that malaria prevents economic growth and keeps the community in poverty and, hence, ensuring a vicious cycle where the poor households experience high malaria burden that in turn traps them in poverty. Similarly, studies have reported that poor socioeconomic status has an adverse impact on the risk of admission for pneumonia, increased diarrhea prevalence,,, and a rise in septicemia and septicemia-related mortalities.,
The increased prevalence in diseases among socially disadvantaged children is possibly due to poor parents' financial strength and other related factors observed such as high unemployment rate, polygamous setting, single parenting, rural residence, and low registration level for health insurance. A higher percentage of the mothers compared to the fathers earned very low income. This may be due to the observed lower educational attainment of the mothers compared to the fathers because salaries are linked to employment positions and academic qualifications. A previous study reported a similar finding with more of the mothers than fathers being poorly educated. Regarding the factor of rural living identified as a disadvantage in 115 (28.75%) of the studied population, rural life is known to combine the problem of lack of essential municipal amenities with those of inadequate provision of healthcare facilities. Children from single parent families are likely to experience poorer health challenge. This is because a single parent depends only on his or her financial ability and this may be very limited. Such families constituted 20.8% of the disadvantages in a previous study compared with 5% in the present study. The disparity observed could partly be due to the time of the studies, the difference in study locations, and the changes in living conditions. The observed significantly higher prevalence of the common infectious diseases as well as neonatal jaundice and PEM is not unlikely due to the ripple effects of unemployment and poverty such as reduced food supply with attendant under nutrition/malnutrition and consequent underweight and stunted growth as observed in the present study, and reduced immunity giving rise to increased susceptibility to infectious diseases.
The duration of illness was the only determinant of social disadvantage among the studied children. The children who were socially disadvantaged presented significantly later to the hospital than their non-socially disadvantaged counterparts following onset of illnesses; this may explain why they had a longer duration of hospital stay. The delayed presentation to the hospital might have led to the worsening of the disease condition, hence, necessitating a longer period of treatment. Low utilization of healthcare services due to delay in making decision and delay in assessing medical services is because of the ripple effects of unemployment and poverty.
| Conclusions|| |
This study has demonstrated that the rates of hospital admissions due to infectious illnesses, particularly malaria, pneumonia, septicemia, diarrhea diseases, meningitis, as well as neonatal jaundice and PEM were significantly higher in the children who are socio-economically disadvantaged. The duration of hospital stay was a determinant of social disadvantage. The children who are socially disadvantaged are at risk of prolonged duration of hospitalization (> 5 days) and are also at higher risk of poor outcome (death). There is a need to address the modifiable socioeconomic inequalities such as parental education, employment, NHIS registration, and family size. This may ensure early presentation to the hospital and improved outcome of illness.
The study protocol did not include visitation of the participants' households to confirm the usage of ITN as a tool, which can influence the incidence of malaria among the studied participants.
We thank all the parents/caregivers and the patients involved in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]