Infections in families with small children: Use of social insurance and healthcare

Abstract

Objective. To examine infectious symptoms on a daily basis in families with small children and how often these infections cause people to stay at home or seek healthcare. Design. A population-based prospective study. Setting. Child health clinics in seven municipalities in Sweden. Subjects and main outcome measures. All family members of 835 families who came with an 18-month-old child to a child health clinic were asked to register all infectious symptoms in a diary for a month. They were also asked to indicate whether they had stayed at home from day-care or school, whether social insurance had been used, and whether they had contacted healthcare facilities or seen a physician. Results. In total, 7% of the 18-month-old children and 34% of the parents had no symptoms during the winter month. The most common symptom was a runny nose. The 18-month-old children had 1.6 symptom episodes with an average duration of 5.6 days. Of the symptom episodes 13% led to contact with healthcare facilities and 6% to an antibiotic prescription. Of the symptom days 27% required staying at home and in 10% social insurance was claimed. Conclusion. Symptoms of infection among families with small children were common, with a runny nose being the most common. Physician consultations and antibiotic prescriptions were used in a small proportion of the symptom episodes. Social insurance was claimed in about one-third of the days with absence from day-care.

• Care utilization
• family
• family practice
• infections
• preschool children

Introduction

Respiratory tract infection is the most common diagnosis in primary care [1]. It is most common in the youngest children; those aged up to three years contract on average five respiratory tract infections a year, but with rising age the frequency falls to two per year in the twenties [2–5]. An increased frequency of infections has been noted in women around the age of 20 to 25, and for men a few years later [2]. Boys have higher morbidity than girls until the age of two, after which the figures are reversed [2–5].

A Swedish study showed that 61% of all health problems were caused by infectious symptoms [6] and another that 60% of children between the ages of 0 and 6 had a health problem of some kind during a four-week period [7]. In Sweden the majority of parents are employed outside the home [8]. The Swedish social insurance system enables a parent to stay at home to take care of an ill child with compensation for loss of earnings, for a maximum of 60 days a year [9]. We have not found any study charting in detail all the infectious symptoms occurring during a month in families with small children or analysing the measures taken because of these symptoms.

Respiratory tract infections are common in small children.

• On average an 18-month-old child has 1.6 infectious episodes during a winter month.

• In 13% of the episodes physician consultation was made and in 6% antibiotics were prescribed.

• In 10% of the days with absence from day-care because of illness, social insurance was used.

The aim of this study was to obtain a population-based picture of the infectious symptoms that occur in families with small children, where at least one child was 18 months old, and relate this to how often they stayed at home, claimed social insurance, or contacted healthcare facilities.

Material and methods

Seven municipalities took part, two urban and five rural municipalities in southern and central Sweden. The number of inhabitants was between 54 600 and 118 000 in the urban municipalities and between 15 300 and 19 000 in the rural. The nurses working at the child health clinic informed about the study, in writing and orally, the parents who came for routine checkups with an 18-month-old child. The families were included consecutively from 1 October 2002 until 11 April 2003. The families who accepted gave written consent and received the diary.

Families that had not mastered the Swedish language, in the judgement of nurses at the child health clinic, were not included.

Questionnaire

All families had to answer a questionnaire regarding socioeconomic status, ethnicity, smoking in the family, child day-care, and whether they thought they were prone to infections, or had asthma/allergy.

Diary

During one month all the family members had to note all infectious symptoms in a diary, according to the set alternatives: runny nose, cough, earache, sore throat, temperature, more than 38°C, diarrhoea/vomiting or other symptoms. In the diary they also noted whether they had been at home from day-care, school, or work, if they had claimed social insurance, and whether they had visited a physician or received antibiotic treatment.

All families received a fridge magnet with a spring clip in which the diaries could be collected. Nurses from the child health clinic phoned the family twice during the month to remind them about the registration and that the diaries should be sent in, in the envelope with prepaid postage.

Definitions

A symptom day was defined as a day when one or more symptoms occurred. A symptom episode was defined as the occurrence of one or more infectious symptoms during at least one day. A new symptom episode was registered as starting if there were at least two days without symptoms since the previous symptom episode. When counting the number of symptom episodes, all episodes beginning during the registration were included, and when calculating the number of days per episode we used all complete symptom episodes. Respiratory tract symptoms were defined as at least one of the following: runny nose, cough, earache, sore throat, with or without tiredness and fever. Gastroenteritis was defined as diarrhoea or vomiting with or without tiredness and fever and without the occurrence of other symptoms.

Statistical analysis

The statistical analyses were performed with SPSS (Version 12.0.1) software. A Mann–Whitney U-test was used to compare numerical variables in two independent groups. Logistic regression analysis was used to test for differences in categorical variables between groups and ANOVA to test for differences in means of continuous variables.

Ethics

The study was approved by the committees on research ethics in Linköping, Lund, and Uppsala.

Results

A total of 1185 families in the geographical area studied had children who reached the age of 18 months during the study period. Seven families did not visit the child health clinic and 38 families were not invited to take part in the study because of language difficulties in accordance with the exclusion criteria. Thus 1140 families were asked to take part in the study. Of those 154 declined without stating any reason, 30 because of their difficult social situation, and 2 moved away during the period of the study. Thus a total of 84% (954/1140) of the families were included. Of those who consented to take part, 87% (831/954) completed the diary registrations.

In the 831 participating families there were 1552 children, of whom 55% (848/1552) were 18 months old. In 58% (483/831) of the families there were siblings, of whom 26 were under 18 months of age. These 26 were excluded in the further analyses. The mean number of children per family was 1.9. In 4.4% of the families there was only one adult and in 12% there was at least one smoker. Some 74% of the families lived in detached houses. In 41% the mother had post-high-school education while the figure for fathers was 38%. Of the mothers 5% were unemployed and of fathers 2%. Asthma and allergy were reported more often in boys than girls. A majority of the children had group day-care outside their home (Table I).

Table I.  Background data for individuals in different age groups.

	%
	18 months		Siblings			Parents
	Girls	Boys	19m–3 y	4–6 y	7–17 y	Mothers	Fathers
	n=408	n=440	n=172	n=272	n=227	n=828	n=792
Born outside Scandinavia	0.7	1	1	1	5	7	7
In group day-care	67	68	75	93	0	–	–
Reported infection prone	15	18	7	6	6	2	3
Reported asthma or allergy	7	13	13	15	20	24	24
Other reported illness or disability	2	1	5	3	4	6	3

The proportion of children without symptoms increased with rising age (Table II).

Table II.  Days with and without symptoms during a month (%).

	%
	18 months		Siblings			Parents
	Girls	Boys	19m–3 y	4–6 y	7–17 y	Mothers	Fathers
Number of day with symptoms	n=408	n=440	n=172	n=272	n=227	n=828	n=792
0	7	7	13	18	34	31	37
1–7	29	28	43	52	45	39	42
8–14	30	30	25	22	17	19	13
15–	34	35	19	8	4	11	8

Different constellations of symptoms could occur during one day, but a runny nose was the most frequent symptom in all age groups (Table III).

Table III.  Occurrence of different symptoms in percentages of reported symptom days, in different age groups.

	%
	18 months		Siblings			Parents
	Girls	Boys	19 m–3 y	4–6 y	7–17 y	Mothers	Fathers
Symptoms	n=4776	n=5293	n=1398	n=1602	n=901	n=4801	n=3429
Respiratory^1	82	81	81	79	80	81	78
Runny nose only	30	27	28	28	26	29	26
RTI with fever	9	11	7	7	6	3	4
Gastroenteritis^2	4	5	5	6	5	4	5
Mixed respiratory and gastroenteric^3	10	10	8	10	8	8	9
Other^4	4	4	4	5	7	7	8

¹Respiratory symptom was defined as the occurrence of at least one of the following: runny nose, cough, sore throat, earache with or without tiredness and fever. ²Gastronteritis was defined as diarrhoea or vomiting with or without fever and without other symptoms. ³Mixed symptoms were defined as a combination of respiratory and gastroenteric symptoms on the same day. ⁴Other symptoms were defined as other symptoms with or without tiredness and fever.

The 18-month-old children had on average 1.6 infectious episodes compared with 1.0 for the oldest siblings. Days per episode, physician visits and antibiotic consumption are shown in Table IV. No statistically significant differences were found between the sexes.

Table IV.  Symptom episodes and measures taken, in different age groups.

	Mean (SD)
	18 months		Siblings			Parents
	Girls	Boys	19m–3y	4–6 y	7–17 y	Mothers	Fathers
Symptom episodes	n=703	n=771	n=270	n=396	n=290	n=1139	n=984
Days per episode	5.7(4.6)	5.4(4.4)	5.1(4.1)	4.0(3.4)	3.8(2.7)	4.3(3.7)	3.9(3.3)
Physician visits per episode	0.12(0.4)	0.15(0.4)	0.09(0.4)	0.08(0.3)	0.04(0.2)	0.05(0.2)	0.06(0.5)
Antibiotic prescriptions per episode	0.05(0.2)	0.07(0.2)	0.04(0.2)	0.05(0.2)	0.02(0.2)	0.03(0.2)	0.02(0.1)

Children aged 18 months had more symptom days per episode than older siblings (p<0.001). The 18-month-old children made more physician visits than siblings older than four years (p<0.001) and consumed more antibiotics than siblings older than seven (p=0.02).

The mothers had 1.1 infectious episodes compared with 0.9 for the fathers (p<0.001) and the mothers consumed more antibiotics per episode (p=0.04).

Eighteen-month-old children from smoking families did not have more infectious episodes (p=0.09) or days per episode (p=0.50) than children from families without smokers. When adjusting for sex, there were no differences in physician visits, OR 0.93 (95% CI 0.56–1.52) or antibiotic consumption, OR 1.46 (95% CI 0.80–2.65), for children from smoking or non-smoking families.

On 23–30% of the symptom days the children had to stay at home from day-care or school, but social insurance was seldom claimed when the children were ill. It was claimed for 75% of the days by mothers and 77% of the days by fathers (Table V).

Table V.  Percentage of days at home and utilization of social insurance: Data are based on symptom days reported by all the individuals who had day-care outside home.

	%
	18 months		Siblings			Parents
	Girls	Boys	19 m–3 y	4–6 y	7–17 y	Mothers	Fathers
	n=3313	n=3911	n=1019	n=1514	n=901	n=4801	n=3429
At home	24	30	23	27	23	12	13
Use of social insurance	9	10	6	6	2	9	10

Discussion

During one winter month, more than 80% of the children below six years of age had some reported symptoms, with a runny nose being most frequent. Only a small proportion of all symptom days led to contact with healthcare facilities and use of social insurance.

In Sweden 99% of all families visit a child health clinic [10], which provides excellent opportunities to perform good population-based studies on young children. The high attendance at the child health clinic, and the fact that the nurses reminded families on two occasions, facilitated the satisfactory result that 73% completed the study.

Diaries have previously been used to study morbidity and healthcare utilization. They give a more detailed picture of daily symptoms and measures than a retrospective interview, above all when it comes to minor and mundane events [11]. Diaries make it possible to follow an event through time, and a large amount of information can be obtained at a low price [12]. One precondition is that the diaries are filled in continuously, which requires commitment.

Early population-based studies from the twentieth century have described the frequency of infectious symptoms, above all from the respiratory tract [13], among both adults [4], [14] and children [4], [15]. Later studies have also investigated which aetiological agents occur in respiratory tract infections, the best-known being the Tecumseh study [2], [3], [16]. Since that study was conducted in the USA in the 1970s, a diary study has been performed in Sweden, recording health problems in families with small children [6].

Data in the Tecumseh study were collected by telephone interviews each week [2], [16]. These and some earlier studies demonstrated, just like ours, that the number of episodes falls with rising age [2–5]. The number of episodes of infectious symptoms in our study was higher than in previous studies [2], which could partly be explained by the fact that the selected families had 18-month-old children, an age at which infectious symptoms are common. Another explanation could be that more symptoms are reported when data are registered in diaries than if they are collected by interviews or by telephone [12]. In addition, our study period was in the winter season, which is the time when most infections occur [3], [4], [16], [17].

In our study the episodes were much shorter than in the Tecumseh study, which might partly be explained by differences in definition of an infectious episode.

Symptoms from the respiratory tract, occurring either singly or multiply, are still by far the most common infectious symptoms [16] and the distribution of symptoms seems not to have changed over time. The proportion of gastroenteritis episodes seems to be stable at around 10% [18].

As in another study, we did not find any clear differences between the sexes among children in the number of infectious episodes and symptom days [19]. Other studies we found that, below the age of about two years, boys have higher morbidity than girls, after which girls have higher morbidity [2], [3]. In concordance with other studies mothers reported higher morbidity than fathers [2], [4], [5], [14].

In this study only 1.7–4.0% of all reported days with infectious symptoms and about 13% of the symptom episodes in the youngest children led to physician consultations. We have not found any other directly comparable studies but earlier Swedish studies have shown that roughly 10% of self-perceived health problems lead to some contact with a physician the healthcare facilities and at least 40% of the population makes one physician visit a year [6], [12], [20], [21]. For most of the episodes there was no need to contact healthcare facilities, a pattern that has not changed noticeably during the last 20 years. However, infectious diseases are the most common reason for physician consultation [22].

Earlier studies have resulted in contradictory results regarding the influence on infectious symptoms, physician visits, or antibiotic consumption of smoking in the family [17], [19], [23–28]. In this study we did not find any differences in infectious symptoms, physician visits, or antibiotic consumption between children from smoking or non-smoking families.

Roughly 25% of the symptom days in the children and about 13% in the parents caused absence from day-care, school, or work. No studies, to our knowledge, have related reported infectious symptoms to how often one need stay at home from day-care, school, or work. In Sweden the social insurance system in general is generous, i.e. parents can receive financial compensation if they have to stay at home with an ill child. Social insurance was thus claimed for only a small proportion of the days the child had to be cared for at home. This means that the parents must have made arrangements for their ill children to be looked after in other ways, despite the possibility of using the social insurance scheme.

Conclusion

Infectious symptoms in families with small children are common. One-quarter of the symptom days led to absence from day-care, school, or work, and in an even smaller proportion of the symptom days social insurance was claimed. A small proportion of the infectious episodes led to physician consultation and antibiotic prescription.

The study was supported by STRAMA (Swedish strategic programme for rational use of antimicrobial agents and surveillance of resistance), Landstingsförbundet (the Federation of Swedish County Councils (FCC), the Centre for Clinical Research, Dalarna County Council, and the Unit for Research and Development Kronoberg County Council.