Scientific Grounds for the Organization of Sanatorium Care for Children of Preschool Age with Tuberculosis Infection

The dissertation is devoted to the scientific grounds for the organization of sanatorium care for children of preschool age who are sick and infected with tuberculosis. The research covers the medico-social, psychological, and organizational aspects of sanatorium treatment of children with tuberculosis infection, analyzes the history of the formation of sanatorium care in Russia, including the activities of the children's tuberculosis sanatorium "Pearl". The work presents a medico-social characterization of families and preschool children undergoing treatment in the sanatorium, identifies psychological characteristics of a child with tuberculosis infection, assesses the health status of patients and the level of parental awareness of the disease. The author developed a complex of measures aimed at the optimization of the organization of therapeutic and preventive care for children in the conditions of a tuberculosis sanatorium and proposed scientifically grounded medico-social and organizational recommendations for improving sanatorium care for this category of patients.

Relevance of the Research. At present, the problem of tuberculosis, after a period of diminished interest, is attracting increasing attention year by year. Tuberculosis occupies a special place among social diseases. The system of phthisiological care formed in Russia at the beginning of the last century, with the special attention that the state devoted to this problem, yielded tangible results. The morbidity and mortality of the population from tuberculosis were steadily declining. The lowest indicators of primary tuberculosis morbidity in Russia were recorded in 1991 (34.0 per 100 thousand), and mortality — in 1989 (7.4 per 100 thousand). However, in the early 1990s, morbidity and mortality from tuberculosis began to rise rapidly, and by 2000 they reached: primary morbidity — 85.2, and mortality — 20.0 per 100 thousand (Yuryeva M.A., 2002). According to specialists' forecasts (Shilova M.V., 2000), further growth of population morbidity with tuberculosis can be expected by 2010 — up to 190.7 per 100 thousand. Moreover, the increase in morbidity was noted not only in Russia but also in most countries of the world (Maher D. et al., 1998; Crofton J. et al., 1998). At present, about one third of the population of our planet is infected with Mycobacterium tuberculosis. Every year approximately 9 million people contract tuberculosis worldwide, of whom about 3 million die from this disease (Medik V.A., Yuryev V.K., 2003; Gaudelius J., 2002). Mycobacterium tuberculosis kills more people than any other infectious agent.

The tense epidemiological situation, coinciding in time with the era of public reforms and the restructuring of the healthcare system in our country, could not but affect child morbidity, which increased from 1991 to 2001 from 8.6 to 17.9 per 100,000 child population of the Russian Federation, with the rate of increase in childhood tuberculosis morbidity in the Russian Federation being twice that of adults (Aksenova V.A., 2000; Shilova M.V., 2001). In this regard, the problems of timely detection, prevention, and treatment of tuberculosis in children acquire particular relevance. This is the task of the phthisiological service, including such its branch as the children's tuberculosis sanatorium (CTS).

The sanatorium stage is recognized as an important link in the conduct of a full course of specific and pathogenetic therapy of tuberculosis in children (Yanchenko E.N., Greimer M.S., 1999; Aksenova V.A., 2000; Lebedeva I.B., 2002). It has a distinctive specificity, consisting in both a more diverse patient composition (local forms of varying activity, extrapulmonary forms, infected with MTB) and its special goals (examination and rehabilitation of patients and infected individuals, rehabilitation), methods of achieving which (wide application, alongside etiotropic therapy, of pathogenetic, non-pharmacological, and natural factors of treatment, sanitary-hygienic regime). The Federal Law "On Prevention of the Spread of Tuberculosis in the Russian Federation" No. 77-FZ of 18.06.01 emphasizes the role of CTS in the fight against tuberculosis. Nevertheless, sanatorium care for infected and sick tuberculosis children is in a state of protracted crisis associated with problems of healthcare and society as a whole (Puchkov K.S. 2001, Isaeva N.Yu. 2001, Istoshin M.G. 2001).

Works devoted to the activities of CTS and the medico-social study of children undergoing treatment there are very few in modern literature; they mainly concern schoolchildren and adolescents (Isaeva N.Yu., 2001; Lozovskaya M.E., 2003; Krivokhiz V.N., 2004). Despite the fact that tuberculosis infection treatment begun in a hospital usually concludes under sanatorium conditions, sufficient attention to post-stationary, sanatorium care for children has not been given in scientific literature. Targeted investigations of this kind among preschool-age children and their parents have not been conducted.

Goal of the Research. On the basis of a comprehensive medico-social and medico-psychological examination of infected and sick tuberculosis children of preschool age, analysis of the formation and current state of sanatorium care for such children, to develop a complex of measures aimed at the optimization of the organization of therapeutic and preventive care for children in the conditions of a tuberculosis sanatorium.

To achieve the stated goal, the following tasks were set:

1. To study the formation and development of sanatorium care for children with tuberculosis infection.

2. To present a medico-social characterization of children infected and sick with tuberculosis in the conditions of a modern megapolis.

3. To identify psychological characteristics of a child undergoing treatment in a children's tuberculosis sanatorium.

4. To provide a scientific analysis of the state of sanatorium care for children infected and sick with tuberculosis.

5. To investigate parental satisfaction with sanatorium care and the factors determining it.

6. To develop scientifically grounded medico-social and organizational recommendations aimed at improving sanatorium care for children with tuberculosis infection.

Scientific Novelty of the Research. The scientific novelty consists in the fact that for the first time in the conditions of the Northwestern Economic Region a comprehensive multi-faceted scientific analysis of the state of sanatorium care for children with tuberculosis infection is provided; a medico-social portrait of patients of the studied profile is presented; individual-typological personality characteristics are investigated; medical literacy and activity of parents of a child with tuberculosis infection are assessed; and their satisfaction with the provided specialized phthisiological care is studied.

Scientific and Practical Significance of the Work. The scientific and practical significance of the work is determined by the results of the research, which have made it possible to considerably expand existing representations about the socio-hygienic and psychological characteristics of modern children with tuberculosis infection. The conducted research made it possible to present to healthcare administration bodies, as well as practical healthcare organizations, scientifically grounded information about the state and possibilities of optimization of sanatorium care for patients of the given profile. The materials and conclusions of the dissertation research can be implemented in other regions of Russia, and the realization of the complex of proposed medico-social and organizational measures will allow more effective use of available healthcare resources, increase the level of patient satisfaction with the medical care received. The methodological and methodological approaches used in this research can be applied to the development and scientific grounding of other specialized types of sanatorium care for children.

Implementation of the Results of the Dissertation Research. The results of the dissertation research have been implemented in the practical activities of: State Unitary Enterprise "City Anti-Tuberculosis Dispensary of Saint Petersburg"; State Unitary Enterprise "Anti-Tuberculosis Dispensary No. 3 of Saint Petersburg"; State Unitary Enterprise "Leningrad Oblast Anti-Tuberculosis Dispensary"; State Unitary Enterprise "Children's Polyclinic No. 8" of the Central District of Saint Petersburg; the Children's Tuberculosis Sanatorium "Pushkin"; and in the process of teaching at the departments of humanitarian disciplines and bioethics, as well as social pediatrics and healthcare organization of the Continuing Professional Education and Advanced Training (FPKiPP) of the State Educational Institution of Higher Professional Education "Saint Petersburg State Pediatric Medical Academy of Roszdrav".

Main Propositions to be Defended. 1. The formation and development of tuberculosis infection in childhood are influenced by a complex of medico-social factors having different levels of impact depending on the conditions and lifestyle of families. Tuberculosis at present is gradually losing its pronounced features of social pathology, spreading to all social strata.

2. The level of sanitary literacy and medical activity of the population on questions of tuberculosis prevention in children is quite low. Many parents do not observe the principles of prevention and treatment of this infection.

3. The phthisiopediatric service of the city possesses rich historical traditions, has certain achievements in the prevention and treatment of tuberculosis in children, however, it needs improvement of the quality of its work and the introduction of more effective organizational forms, in particular, those proposed in this research.

4. Parents of patients are mainly satisfied with the quality of medical service in the sanatorium; however, further improvement requires observance of ethical and deontological principles by medical personnel, as well as conditions of children's stay.

Author's Personal Contribution to the Conducted Research. The author independently conducted an analytical review of domestic and foreign literature on the studied problem, developed the research design, statistical instrumentation, performed data extraction from primary medical documentation, and conducted questionnaire surveying of parents of patients in the children's tuberculosis sanatorium. The author personally participated in the psychological testing of patients. The compilation of the mathematical-statistical data processing program and the data processing itself were conducted with the author's personal participation. Intermediate results of the research were systematically verified by the scientific supervisor. Analysis, interpretation, presentation of obtained data, formulation of conclusions, and practical recommendations were mainly performed by the author personally. The author's share in information collection is up to 100%, in mathematical-statistical processing — more than 80%, and in generalization and analysis of material — 95%.

Validation of the Work. The main propositions of the dissertation were heard, discussed, and approved at the meetings of: the Outgoing Conference of Heads of Anti-Tuberculosis Dispensary Departments (Saint Petersburg, 2003); the Scientific and Practical Conference "Sanatorium-Rehabilitative Care for Children and Adolescents with Tuberculosis Infection at the Present Stage" (Saint Petersburg, 2004); the Problem-Expert Council of Medico-Social Health Assessments of the State Educational Institution of Higher Professional Education "Saint Petersburg State Pediatric Medical Academy of Roszdrav" (Saint Petersburg, 2005).

Published Works on the Dissertation Topic. 7 scientific works have been published on the dissertation topic.