Abstract
Objective
To describe the organizational and operational capabilities of specialized centres for children with psychomotor disability in Abidjan, Republic of Côte d’Ivoire.
Materials and methods
This descriptive study was carried out from February to May, 2006 at the various specialized centres for children with psychomotor disability that exist in the district of Abidjan. The procedure comprised a clinical description of the disabled children admitted to these centres and an assessment of the centres’ organization and operational capabilities.
Results and comments
Six specialist centres for children with psychomotor disability were identified, namely the Infant Guidance Centre, the Awakening and Stimulation Centre for disabled Children, the “Sainte-Magdeleine” Centre, the Medical and Training Institute, the “Page Blanche” institute and the “Colombes Notre Dame de la Paix” Centre. Among the children, 97.15% were day patients, 66.37% were mentally challenged, 30.96% had psychomotor impairment and 2.66% had motor impairments.
The level of organization varied but the centres nevertheless had operational administrative, medical and paramedical staff, despite the absence of certain specialties. However, the lack of personnel, equipment and infrastructure is hindering the delivery of adequate services to the children.
Conclusion
In Abidjan District, reception centres for children with psychomotor impairments are essentially privately run. Organizational and operational performances were suboptimal, with a low carer-to-patient ratio. Reinforcement of the centres’ operational capabilities appears to be necessary.
Résumé
Objectif
Décrire les capacités organisationnelle et fonctionnelle des centres d’accueil pour enfants handicapés psychomoteurs à Abidjan.
Matériels et méthodes
Il s’agissait d’une étude transversale descriptive sur les différents centres d’accueil pour enfants ayant un handicap psychomoteur et présents dans le District d’ Abidjan. Elle a couvert la période de février à mai 2006. La procédure a comporté d’une part une description des caractéristiques cliniques des enfants handicapés admis dans ces centres et d’autre part une analyse de l’organisation et du fonctionnement de ces centres.
Résultats
Six centres d’accueil pour enfants handicapés psychomoteurs ont été identifiés : le centre de guidance infantile, le centre d’éveil et de stimulation des enfants handicapés, le cabinet Sainte-Magdeleine, l’institut médicopédagogique, la Page Blanche, le centre des handicapés les Colombes Notre Dame de la Paix. La plupart des enfants y étaient admis en régime d’externat (97,15 %) et il s’agissait d’enfants présentant des handicaps psychiques (66,37 %), des handicaps psychomoteurs (30,96 %) et des handicaps moteurs (2,66 %).
Le niveau organisationnel était variable en fonction des centres périphériques spécialisés qui disposaient d’un personnel administratif, médical et paramédical minimum nécessaire pour assurer leur fonctionnement malgré l’absence de certaines spécialités. Le déficit en personnel et l’insuffisance en équipement et en infrastructures ne permettaient pas selon les centres la satisfaction des demandes de soins adaptées à la situation des enfants.
Conclusion
Les centres d’accueil pour enfant handicapé psychomoteur étaient essentiellement des centres privés. Le niveau organisationnel et fonctionnel était moyen avec un taux d’encadrement faible. Le renforcement de leur capacité apparaît nécessaire.
1
English version
1.1
Introduction
The west African state of the Republic of Côte d’Ivoire (also known as Ivory Coast) covers an area of 322,462 square km and has an estimated population density of 43 inhabitants per square km. Côte d’Ivoire’s population increased from 15,446,231 inhabitants in 1998 (according to the General Census, RGPH 1998) ) to 19,096,988 inhabitants in 2005 (a forecast by the National Institute of Statistics, 2005), with a population growth rate of 3.5% (Report on Population Growth, 2005).
The city of Abidjan (Côte d’Ivoire’s economic capital) is situated in the south of the country; its population was estimated to be 3,125,890 in 1998, of whom around 89,000 are disabled (1998). Nationwide, the disabled population increased from 720,000 in 2002 to 1,500,000 in 2005, according to a survey performed by the Côte d’Ivoire’s Ministry for Social Affairs and Handicapped Persons . Disabled children aged 15 or under accounted for nearly 30% of this population, although epidemiological studies on the distribution of the causes of psychomotor handicap are scarce because they concern several medical disciplines (neurology, paediatrics, child psychiatry, neurosurgery, functional rehabilitation, etc.).
The management of children with psychomotor handicaps is multidisciplinary and requires specialist centres whose organisational and operational capabilities must provide appropriate care for the type and level of handicap: it is a question of treating a child with a personal and family history and who will bear long-term sequellae, rather than just treating a disease .
To this end, a specialized reception centre must have good organisational and operational capabilities, i.e. efficient administration (for managing resources properly), appropriate logistic resources (notably appropriate premises, catering facilities and, potentially, residential accommodation) and multidisciplinary care provision that matches the child’s handicap (physiotherapy, psychomotor therapy, speech therapy, occupational therapy, etc.).
In Europe (and notably in France), high-quality organisational and management systems in specialist centres have boosted the academic and socio-economic reinsertion of handicapped children .
In the Republic of Côte d’Ivoire, there is cause for concern; the various national child health programmes and projects do not sufficiently address the needs of children with psychomotor handicaps and there is no mechanism for evaluating the expertise available at the various centres. The matter of the organisational and operational capabilities for care centres for handicapped children in Abidjan District thus remains unresolved.
Hence, the objective of the present study was to:
- •
identify the various centres in the Abidjan District providing care to children with psychomotor handicaps ;
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establish the clinical profile of the paediatric patient population and ;
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describe the centres’ administrative and medical operating modes.
1.2
Materials and methods
We performed a descriptive, cross-sectional study of Abidjan District from February 2006 to May 2006 and included all the local centres focused on care provision for children with psychomotor handicaps. Centres providing psychiatric care only were excluded from the study.
1.2.1
Data sources
We consulted and extracted data held by the Côte d’Ivoire Ministry of Public Health and the various centres’ databases (going back to 1990). This data collection technique was coupled with interviews of the managers at the various centres.
1.2.2
Parameters studied
The parameters studied concerned both the specialized centres and the pathologies of the treated children.
In terms of the centres, we studied:
- •
the organisation of the administrative, medical, paramedical, psychosocial, educational & logistics service and the infrastructure and equipment, on the basis of the data available at the various centres (going back to 1990) and interviews with centre managers;
- •
the centres’ operational capabilities in terms of admission modes, patient care and medical and social activities.
In terms of the disabled children, we studied age, gender, educational level and the aetiology of the handicap (on the basis of the patients’ medical files).
1.2.3
Operational definitions
Children with psychomotor handicaps: for the purposes of this study, we included all children with psychiatric, motor and psychomotor handicaps.
Admission and care modes:
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the source of admission requests (hospitals, healthcare centres, families, etc.);
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admission criteria, bearing in mind a given centre’s care capabilities (prior medical consultations and patient screening interviews);
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the type of care provided (day care/outpatient care or residential care);
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the number of children receiving care at the time of the survey;
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consultation and registration fees;
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care fees for residential patients;
- •
sources of funding;
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personnel recruitment procedures.
Medical and social activities: all the various care activities offered to the children in these centres, specifying the frequency of care provision, the management of social aspects and whether home care was available for day patients.
Age: the children were grouped into three age ranges: zero to five, five to 10 and 10 to 15.
Aetiology: the causes of the children’s handicaps were classified by major disease area: congenital intellectual impairments, encephalitis, central motor, sensory & higher function handicaps, Down’s syndrome and psychoemotional disorders.
1.2.4
Statistical analysis
Data were entered and the results were generated using the MySQL 5.0 database management software. We then calculated proportions and frequencies using Microsoft Excel 2003.
1.2.5
Ethical aspects
The study was approved by the Ministry of Public Health, the Ministry for Social Affairs and Handicapped Persons and the managers of the various centres. Parent associations (if present) in the centres were also sent an information sheet on the study via the respective offices.
1.3
Results
1.3.1
Identification and description of the specialist centres
In Abidjan District, we identified six centres specializing in care provision for children with psychomotor handicaps.
1.3.1.1
The AIPEHP Medical and Training Institute
The apolitical, not-for-profit Association ivoirienne des parents et amis d’enfants handicapés psychiques was founded in 1969 by a group of parents concerned about the future of their mentally handicapped children. The AIPEHP created the Medical and Training Institute ( institut médicopédagogique , IMP) in 1971 and the Medical and Professional Institute ( institut médicoprofessionnel , IMPRO) in 2002.
The IMP specializes in the provision of care, rehabilitation, socioprofessional training and sports activity to children and adolescents with psychomotor handicaps and thus promotes integration into the social and family environments . The AIPEHP has been a member of Inclusion International (formerly the Ligue internationale des associations pour les personnes handicapées mentales ) since 1986 and is also a member of the Fédération panafricaine des associations des personnes handicapées mentales (FEPAPHAM) .
1.3.1.2
National Institute of Public Health/Infant Guidance Centre (INSP/CGI)
The INSP is a public-sector institute created in 1974; it has several departments, including the Infant Guidance Centre (CGI) specializing in the management of psychopathological and psychomotor disorders in children and adolescents .
1.3.1.3
International Catholic Children’s Bureau/Challenged Children Project/ Awakening and Stimulation Centre for disabled Children (centre d’éveil et de stimulation des enfants handicapés) (BICE/EHA project/CESEH)
The disabled Children Project started in 1995 and led to creation of the Awakening and Stimulation Centre for disabled Children (CESEH) . The CESEH is a secular, privately-run centre at which the main activities are teaching, sensory awakening, functional rehabilitation and socioprofessional insertion.
1.3.1.4
Association pour la réinsertion des enfants par une éducation adaptée (AREEA)/Page Blanche
The AREEA is an association that includes the parents of handicapped children, professionals and benefactors. It seeks to coordinate and assist families and professionals with a view to providing handicapped children with an education and, ultimately, socioprofessional reinsertion. The “Page Blanche” is the AREEA’s medical and educational institute. It is a secular, privately-run establishment .
1.3.1.5
Cabinet Sainte-Magdeleine (CSM)
This is a clinic for psychomotor rehabilitation and medical, psychological and educational care created by an educational psychologist in June 2005 . It is a secular, privately-run establishment specializing in learning, play-based stimulation of language and communication, psychomotor rehabilitation and counselling.
1.3.1.6
Colombes Notre Dame de la Paix Handicap Centre (CHCNDP)
The CHCNDP treats psychological and motor handicaps. It was created in October 1999 by the Order of Sisters of Notre Dame de la Paix , in collaboration with a group of educators. It is a confessional, privately-run centre that focuses on socialisation, personal independence and development .
1.3.2
Sociodemographic characteristics of the handicapped children
The mean age of the children in Abidjan’s specialist centres was eight (range: 1 to 15). The largest group of children in the overall study population was that aged from zero to five (35.76%). At the IMP, children aged between 10 and 15 years were the best represented group (57.30%) and at the Page Blanche and the CHCNDP, the children aged from five to 10 were best represented (52% and 46.15%, respectively). Children aged from zero to five years were the most numerous group at the CGI (46.28%), the CESEH (41.41%) and the CSM (48.14%).
Among the children present in Abidjan’s specialist centres, 57.12% were boys (i.e. a male/female gender ratio of 1.33).
In terms of the educational level, 62.28% of the children were attending school (pre-school: 27.58%; primary school: 30.78%; secondary school: 3.91%) and thus 37.72% were not attending school.
The causes of handicap in the children monitored in the centres are presented in Table 1 .
| Centre | AIPEHP IMP | INSP CGI | BICE CESEH | AREEA PB | CSM | CHCNDP | Total (%) |
|---|---|---|---|---|---|---|---|
| Aetiology | Number (%) | Number (%) | Number (%) | Number (%) | Number (%) | Number (%) | |
| Congenital intellectual impairments | 16 (18.0) | 19 (6.4) | 20 (20.2) | 8 (32) | 1 (3.7) | 1 (3.9) | 65 (11.6) |
| Encephalitis | – | 102 (34.4) | 13 (13.1) | 1 (4) | 11 (40.8) | 8 (30.8) | 135 (24.0) |
| Central motor and sensory handicaps | 8 (9.00) | 86 (29.0) | 47 (47.5) | 9 (36) | 11 (40.7) | 1 (3.8) | 162 (28.8) |
| Down’s syndrome | 65 (73.0) | 7 (2.4) | – | – | – | 6 (23.0) | 78 (13.9) |
| Psychoemotional disorders | – | 78 (26.4) | – | 7 (28) | 4 (14.8) | 10 (38.5) | 99 (17.6) |
| Other disorders a | – | 4 (1.4) | 19 (19.2) | – | – | – | 23 (4.1) |
| Total | 89 (100) | 296 (100) | 99 (100) | 25 (100) | 27 (100) | 26 (100) | 562 |
a Other disorders: road accidents, trauma, malformation and poliomyelitis.
1.3.3
Administrative and medical organisation
In 2006, the Abidjan District’s specialist centres employed 113 full-time equivalent staff, i.e. about 20 staff per 100 disabled children.
Of these 113 staff, 28 (i.e. 24.8%) were involved in management or administration and 28 people (24.8%) performed medical and paramedical activities. Personnel in psychosocial and educational services accounted for 50.4%, corresponding to a carer-to-patient ratio of around 10.14% for this type of care. The distribution of the personnel is summarized in Table 2 .
| Specialist Centre | AIPEHP/IMP | INSP/CGI | BICE/CESEH | AREEA/PB | CSM | CHCNDP |
|---|---|---|---|---|---|---|
| Administrative service ( n = 28) | ||||||
| n = 6 | n = 4 | n = 4 | n = 5 | n = 4 | n = 5 | |
| Chairman | 1 | – | – | 1 | – | – |
| Director | 1 | 1 | 1 | – | 1 | 1 |
| Ed. Dir. a | 1 | – | 1 | 1 | 1 | 1 |
| Secretary | 1 | 1 | – | 1 | 1 | 1 |
| SCER a | 1 | 1 | 1 | 1 | – | 1 |
| Accountant | 1 | 1 | 1 | 1 | 1 | 1 |
| Medical service ( n = 12) | ||||||
| n = 2 | n = 3 | n = 1 | n = 2 | n = 3 | n = 1 | |
| Chief physician | – | 1 | 1 | 1 | – | 1 |
| Orthopaedic physician | 1 | – | – | – | – | – |
| Child psychiatrist | 1 | 2 | – | 1 | 1 | – |
| General practitioner | – | – | – | – | 1 | – |
| Neurologist | – | – | – | – | 1 | – |
| Paramedical personnel ( n = 16) | ||||||
| n = 4 | n = 4 | n = 2 | n = 2 | n = 2 | n = 2 | |
| Psychomotor therapist | 1 | 1 | – | – | 1 | 1 |
| Physiotherapist | 1 | – | 1 | 1 | – | – |
| Speech therapist | 1 | 1 | – | 1 | 1 | 1 |
| Nurse | – | 2 | – | – | – | – |
| Nursing assistant | 1 | – | 1 | – | – | – |
| Psychosocial and educational service ( n = 57) | ||||||
| n = 7 | n = 12 | n = 7 | n = 22 | n = 3 | n = 6 | |
| Psychologist | 1 | 1 | 1 | 1 | 1 | 1 |
| Social worker | 3 | 2 | 3 | 5 | – | – |
| Specialist educator | 3 | 9 | 3 | 9 | 2 | 3 |
| Pre-school educator | – | – | – | 2 | – | – |
| Arts & crafts teacher | – | – | – | 1 | – | 1 |
| SGT a | – | – | – | 1 | – | 1 |
| Art therapy teacher | – | – | – | 1 | – | – |
| Childminder | – | – | – | 2 | – | – |
a Ed. Dir: educational director; SCER: secretary in charge of external relations; SGT: special gymnastics teacher.
Depending on the specific needs and resources, the centres were managed by an administrative council chairperson, a director, a management assistant, a secretary in charge of external relations and an accountant.
The number of consulting physicians in the centres ranged from one to three. The number of paramedical staff providing care ranged from two to four. The psychosocial and educational services had much higher staff numbers, ranging from three to 22 ( Table 2 ).
1.3.4
Operation of the centres
The applications for admission to the specialist centres came from various sources (private & public hospitals and healthcare centres ) and were prompted by either healthcare professionals or the parents ( Tables 3 and 4 ).
| Specialist centres | AIPEHP/IMP | INSP/CGI | BICE/CESEH | AREEA/PB | CSM | CHCNDP |
|---|---|---|---|---|---|---|
| Source of admission request | All sources | All sources | All sources | All sources | All sources | All sources |
| Admission criteria | Presence of appropriate specialists and equipment for the type of handicap, participation of the parents in the interview | Presence of appropriate specialists and equipment for the type of handicap, participation of the parents in the interview | Presence of appropriate specialists and equipment for the type of handicap, participation of the parents in the interview, age < 17 | Presence of appropriate specialists and equipment for the type of handicap, participation of the parents in the interview, age < 22 years | Presence of appropriate specialists and equipment for the type of handicap, participation of the parents in the interview, age < 17 | Presence of appropriate specialists and equipment for the type of handicap, participation of the parents in the interview |
| Type of care | Residential and day care | Day care | Day care | Day care | Day care | Day care |
| Current number of children | 89 patients | 296 patients | 99 patients | 25 patients | 27 patients | 26 patients |
| Consultation and/or registration fees | Free | €2 | €3 | €15 | €7.50 euro per session | €686 per year |
| Care fees | €571 per year | €12 per month | €150 per month | – | – | |
| Funding source(s) | Donations and care fees | State funding | Donations | Donations, parents’ subscription, income-generating activities | Consultation fees | Donations, registration and care fees |
| Mode of personnel recruitment | Secondment by the state, recruitment by the centre. | Secondment by the state. | Secondment by the state, recruitment by the centre. | Secondment by the state, recruitment by the centre. | Secondment by the state, recruitment by the centre. | Secondment by the state, recruitment by the centre |
| Specialist centre | AIPEHP/IMP | INSP/CGI | BICE/CESEH | AREEA/PB | CSM | CHCNDP |
|---|---|---|---|---|---|---|
| Consultation | Orthopaedic physician and child psychiatrist: 2 times a week | Child psychiatrist: Daily | General practitioner: Weekly | Child psychiatrist: 4 times a week. | General practitioner: 2 times a week | General practitioner: Weekly |
| Child psychiatrist: Weekly | ||||||
| Neurologist: Appointment | ||||||
| Care given | Psychomotor therapy, physiotherapy, speech therapy, psychology: 2 times a week. | Psychomotor therapy, speech therapy, psychology and nursing care: Daily | Physiotherapy, psychology and nursing care: Daily | Physiotherapy, speech therapy, special gymnastics and psychology: 4 times a week. | Psychomotor therapy, speech therapy and psychology: Daily | Psychomotor therapy, speech therapy, special gymnastics and psychology: 2 times a week |
| Nursing care: Daily | ||||||
| Social management policy | Free care | Free care | Free care | Third-party payer | Third-party payer | Third-party payer |
| Home care | Available | Available | Available | Available | Available | Available |
Admission to the centres was subject to prior examination of the applicant child and an interview with the parents, and depended on the level of equipment.
Care in these centres was variously provided on an outpatient or residential basis.
The centres’ funding came variously from donations, medical and consultation fees, income-generating activities, state funding and members’ subscription fees.
The administrative, medical and education personnel working in these centres were either directly recruited by these centres or seconded by the state.
Regarding the organisation of medical and social activities, each structure had elaborated its own procedures, which are summarized as follows:
- •
specialist consultations were organized once or twice a week;
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the care required by the admitted children was multidisciplinary and depended on the centre in question (psychomotor rehabilitation, physiotherapy, speech therapy, psychology, nursing care, special gymnastics, etc.);
- •
the management of social issues was oriented towards free care in some centres or third-party payment in others;
- •
all centres offered some form of home care for day patients.
1.4
Discussion
The high proportion of handicapped children in the Republic of Côte d’Ivoire should prompt the implementation of competent reception and care centres which are able to ensure the health, safety and well-being of the children entrusted to them. These organisations should also help the children develop and integrate socially by providing assistance to the parents, so that the latter can best manage their professional activity and family life. Legislative progress (the 1998 Disabled Persons Act), social & educational assistance (the provision of €88,500 in State funding for disability care organisations in 2000, i.e. 0.003% of the national budget) and efforts in the field of integration (preferential recruitment of handicapped people, enabling the latter to benefit from stable, salaried employment) have not prompted the creation of specialist centres. Of the six identified centres in Abidjan District, only one is run by the public sector and was founded back in 1974. Almost all centres are private initiatives by non governmental organisations. The scarcity of financial, material and psychoeducational resources explains the observed lack of some of the skills required for care provision, depending on the organisational structures and levels of expertise found in these centres. This situation echoes the general situation in the many African countries which attach low priority to healthcare policy.
Admission to these centres mainly occurs after the age of 5, in view of the limited number of places and the general lack of technical facilities for under-fives. According to a 2001 survey of establishments and services for handicapped children and adults in France, rehabilitation institutes mainly host boys, who account for 81% of the patients. 57% of the youngsters were between 11 and 15. Conversely, there are very few children under six and young adults over 20 in rehabilitation institutes, since they represent less than 1% of the population . However, this could be explained by the fact that they are cared for in other establishments, such as home care services and special schools.
The clinical profiles of the children admitted to the Abidjan District care centres were very varied but predominantly corresponded to central motor disorders and sensory & higher function disorders (28.82% of the study population) and the sequellae of encephalitic conditions (24.02%).
Analysis of the characteristics of the specialist centres for handicapped children revealed that five out of six (i.e. 83%) had been created by an association, a religious congregation or a private organisation. Only one centre in Abidjan District was state-run. In France, there were 342 rehabilitation institutes potentially capable of receiving handicapped children, of which 85% are run by an association, a religious congregation or a charitable foundation, according to the 2001 survey ES . These very similar figures emphasize the significant role played by private-sector organisations in the operation of reception centres for handicapped children.
The children admitted to the specialist centres were monitored by staff with varying levels of skill. Most establishments were multidisciplinary, in order to host the children as well as possible, given the diversity of their situations. Hence, staff recruitment depended on the centres’ resources. The overall staff-to-patient ratio of 5 was low, compared with that found in institutes in Europe (around 1.4) . About 24.8% of the personnel in these centres were involved in management or administration, 24.7% were performing medical and paramedical activities and more than half of the personnel (50.4%) performed educational, teaching and social activities, yielding an inadequate, specific carer-to-patient ratio of around 10.
In terms of operating procedures, all the reception centres performed consultations for children with psychological disorders, behavioural disorders, language difficulties, learning disorders and so on. In most centres, care was provided on an out-patient basis with a view to achieving the prime objective – integrating the child into its family, social and school environments . All centres provided multidisciplinary care and rehabilitation for handicapped children, often on a home care basis. The multidisciplinary care teams were composed as a function of a centre’s recruitment capacities and included specialist physicians, physiotherapists, psychologists, pre-school learning specialists, psychomotor therapists, social workers and speech therapists. None of these centres had a physical medicine and rehabilitation specialist, despite the fact that the latter is a key player in coordinating multidisciplinary care for handicapped people .
The multidisciplinary care teams were headed by an administrative director or a chief physician, as reported elsewhere .
1.5
Conclusion
The Abidjan District’s reception centres for children with psychomotor handicaps are essentially private-sector organisations, whose the very basic organisation and operational capabilities explain the low observed carer-to-patient ratio. Even though the private sector is heavily involved in the development and operation of this type of centre in Europe (and in France particularly), there is a need in the Republic of Côte d’Ivoire to ensure minimum standards of care, which often change without prior consultation with the government ministries in charge of healthcare and social affairs by taking advantage of legislative and regulatory weaknesses.
To resolve this situation, the State’s action must be part of a programme for reinforcing the institutional, medical and technical capabilities by implementing appropriate administrative, logistic, medical, paramedical, psychosocial and educational resources and thus enabling the children admitted to these reception centres to gain personal independence and integration.
2
Version française
2.1
Introduction
Située en Afrique de l’Ouest, la Côte d’Ivoire couvre une superficie de 322 462 km 2 avec une densité démographique estimée à 43 habitants par km 2 . La population ivoirienne est passée de 15 446 231 habitants selon Recensement général de la population et de l’habitat de 1998 (RGPH 1998) à 19 096 988 habitants en 2005 (projection Institut national de la statistique, 2005) avec un taux de croissance démographique de 3,5 % (Rapport sur le développement humain (2005).
Abidjan, capitale économique de la Côte d’Ivoire, est une mégapole située au sud du pays ; sa population était estimée à 3 125 890 habitants en 1998 avec une population des personnes handicapées estimée à 89000 (1998). Cette population de personnes handicapées est passée à 720 000 (2002) puis à 1 500 000 (2005) selon l’enquête réalisée par le ministère ivoirien des Affaires Sociales et des Personnes Handicapées en 2005 . Les enfants handicapés âgés de moins de 15 ans représentaient près de 30 % de cette population mais les études épidémiologiques sur la distribution des causes du handicap psychomoteur sont rares parce que difficiles intéressant plusieurs disciplines médicales (neurologie, pédiatrie, pédopsychiatrie, neurochirurgie, rééducation fonctionnelle…).
La prise en charge des enfants handicapés psychomoteurs est multidisciplinaire à travers des structures spécialisées dont l’organisation et le fonctionnement doivent permettre d’offrir des soins adaptés au type et au niveau du handicap des enfants, parce qu’il ne s’agit pas de traiter une maladie mais un enfant avec son histoire personnelle et familiale et qui va garder des séquelles à long terme .
Pour cela, un centre engagé dans l’action médicosociale doit se doter d’une organisation et d’un fonctionnement performant à savoir une bonne administration à bien gérer les ressources, des moyens logistiques adaptés notamment des locaux adaptés et des possibilités de restauration et éventuellement d’hébergement, une offre de soins polyvalents adaptés au handicap de l’enfant (la kinésithérapie, la psychomotricité, l’orthophonie, l’ergothérapie….).
En Europe, précisément en France, un bon système organisationnel et de prise en charge dans les structures spécialisées, a favorisé la réinsertion académique et socio-économique de ces enfants .
En Côte d’Ivoire, la situation est préoccupante ; les différents programmes et projets de santé infantile au plan national intègrent moins le problème des enfants handicapés psychomoteurs avec à la clé une absence de mécanisme d’évaluation des compétences des centres disponibles. La problématique sur l’organisation et le fonctionnement des centres d’accueil pour enfants handicapés dans le district d’Abidjan reste donc entier.
L’objectif donc de cette étude était de recenser les différents centres du district d’Abidjan prenant en charge les enfants présentant des handicaps psychomoteurs, de décrire le profil clinique de la population des enfants pris en charge et le fonctionnement de ces centres tant au plan administratif que clinique.
2.2
Materiels et méthodes
Il s’agissait d’une étude transversale descriptive réalisée dans le district d’Abidjan de février 2006 à mai 2006.
Ont été inclus tous les centres périphériques orientés dans la prise en charge des enfants handicapés psychomoteurs et présents dans le district d’Abidjan à l’exclusion des centres à caractère purement psychiatrique.
2.2.1
Source de données
Nous avons consulté et exploité les fonds documentaires du ministère ivoirien chargé de la santé publique et la base de données disponibles des différents centres depuis 1990. Cette technique de recueil des données a été couplée à une interview des responsables des différents centres d’accueil.
2.2.2
Paramètres étudiés
Les paramètres étudiés concernaient aussi bien les centres spécialisés que les pathologies des enfants pris en charge :
- •
concernant les centres, nous avons étudié :
- ∘
d’une part l’organisation du service administratif, du service médical, du service paramédical, du service psychosocial et éducatif, du service logistique, infrastructures et les équipements à partir des données disponibles dans les différents centres depuis 1990 et à partir également des informations obtenues au cours de l’entretien avec les acteurs,
- ∘
d’autre part le fonctionnement de ces centres en ce qui concernait l’accès et accueil et les activités médicosociales ;
- •
concernant les enfants handicapés ont été analysés l’âge, le sexe, le niveau scolaire, l’étiologie du handicap à partir des cahiers ou fiches d’observation des patients.
2.2.3
Définitions opérationnelles
Enfant handicapé psychomoteur : ce sont dans cette étude tous les enfants atteints de handicaps psychiques, moteurs et psychomoteurs.
Accès et accueil : les éléments recherchés étaient :
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l’origine des demandes (hôpitaux, centres de santé, particulier…) ;
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les conditions d’admission : il s’agissait des critères d’admission tenant compte de la capacité de prise en charge du centre. La consultation médicale préalable et l’entrevue des parents faisaient le tri ;
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le type de régime d’admission : il s’agissait du régime d’externat (suivi ambulatoire) et du régime d’internat ;
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l’effectif des enfants suivi à la date de l’enquête ;
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les frais de consultation et ou d’inscription ;
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les frais de séjour pour les cas internés ;
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les sources de financement ;
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le mode de recrutement du personnel.
Activités médicosociales : ce sont toutes les activités de soins offerts aux enfants dans ces centres en précisant le rythme de la prise en charge. Ont été précisés également la politique de gestion des cas sociaux et la possibilité ou non de suivi à domicile pour les enfants externes.
Âge : les enfants ont été repartis en trois tranches d’âge : zéro à cinq ans, cinq à dix ans et dix à 15 ans.
Étiologie : les causes du handicap des enfants ont été regroupées dans des grands groupes nosologiques : les déficiences intellectuelles congénitales, les encéphalites, les infirmités motrices cérébrales et les infirmités motrices d’origine cérébrale, les trisomies, les troubles psychoaffectifs.
2.2.4
Analyse statistique
La saisie s’est faite sur le gestionnaire de base de données MySQL 5.0.
Les résultats ont été obtenus à partir du gestionnaire de base de données.
Nous avons ensuite calculé les proportions et réalisé des tableaux de fréquences à partir du logiciel Microsoft Excel 2003.
2.2.5
Aspect éthique
L’étude a été réalisée après accord du ministère chargé de la santé publique, du ministère chargé des affaires sociales et des personnes handicapées et des responsables des différents centres périphériques. Les associations des parents d’enfants handicapés quand elles existaient dans les centres avaient également reçu un courrier d’informations précisant l’objet de l’étude par le biais de leurs bureaux respectifs.
2.3
Résultats
2.3.1
Identification et présentation des centres spécialisés
Dans le District d’Abidjan, nous avons identifié six centres périphériques spécialisés dans la prise en charge des enfants handicapés psychomoteurs.
2.3.1.1
Association ivoirienne des parents et amis d’enfants handicapés psychiques/institut médicopédagogique (AIPEHP/IMP)
L’AIPEHP est une association créée en 1969 à l’initiative d’un groupe de parents soucieux du devenir de leurs enfants handicapés mentaux. C’est une association à but non lucratif et apolitique. En 1971, l’AIPEHP créa l’institut médicopédagogique (l’IMP) et en 2002 l’institut médicoprofessionnel (IMPRO).
L’IMP est une institution spécialisée dans la prise en charge des enfants et adolescents handicapés psychomoteurs. C’est une structure ayant pour vocation l’encadrement, la rééducation, la formation socioprofessionnelle et sportive des enfants et adolescents handicapés. Elle favorise ainsi leur intégration dans le milieu social et familial . L’AIPEHP est membre de la ligue internationale des associations pour les personnes handicapées mentales (LIHM) depuis 1986 et de la Fédération panafricaine des associations des personnes handicapées mentales (FEPAPHARM) .
2.3.1.2
Institut national de santé publique/centre de guidance infantile (INSP/CGI)
L’INSP est un institut public crée en 1974 ; il renferme plusieurs services dont le centre de guidance infantile (CGI) qui est un service spécialisé dans la prise en charge des troubles psychopathologiques et psychomoteurs de l’enfant et de l’adolescent .
2.3.1.3
Bureau international catholique de l’enfance/projet Enfants Handicapés/centre d’éveil et de stimulation des enfants handicapés) (BICE/projet EHA/CESEH)
Le projet Enfants Handicapés a été initié en 1995. De celui-ci découle le centre d’éveil et de stimulation des enfants handicapés (CESEH) . Le CESEH est un centre privé laïc dont les activités principales sont la formation, l’éveil précoce, la rééducation fonctionnelle et l’insertion socioprofessionnelle.
2.3.1.4
Association pour la réinsertion des enfants par une éducation adaptée/Page Blanche (Areea/Page Blanche)
L’Areea est une association regroupant des parents d’enfants handicapés, des professionnels et des personnes de bonne volonté. Ses activités visent à organiser et à mobiliser les familles et les professionnels aux fins de donner une éducation aux enfants handicapés débouchant sur leur réinsertion socioprofessionnelles. La Page Blanche est l’institut médicoéducatif (IME) de l’Areea. C’est une institution privée laïc .
2.3.1.5
Cabinet Sainte-Magdeleine (CSM)
C’est un établissement de rééducation psychomotrice et de suivi médicopsychopédagogique, créé par un psychopédagogue en juin 2005 . C’est un établissement privé laïc spécialisé dans l’apprentissage cognitif, l’éveil ludique du langage et de la communication, la rééducation psychomotrice et l’écoute en relation d’aide.
2.3.1.6
Centre des handicapés les Colombes Notre Dame de la Paix (CHCNDP)
Le CHCNDP est une structure pour handicapés psychiques et moteurs, crée le 27 Octobre 1999 par la congrégation des sœurs Notre Dame de la Paix, en collaboration avec un groupe d’éducatrices. C’est un centre privé confessionnel orienté vers la socialisation, l’autonomisation et le développement .
2.3.2
Caractéristiques sociodémographiques des enfants handicapés
L’âge moyen des enfants des centres spécialisés à Abidjan était de huit ans avec des extrêmes d’un et 15 ans. Globalement, les enfants âgés de zéro et cinq ans prédominaient dans la population totale d’étude (35,76 %). De façon spécifique à l’IMP les enfants dont l’âge variait entre dix et 15 ans étaient majoritaires (57,30 %) ; à la Page Blanche et au CHCNDP les enfants âgés de cinq à dix ans étaient les plus représentés respectivement dans 52 et 46,15 % des cas ; quand au CGI, au CESEH, et au CSM, les enfants âgés de zéro à cinq ans étaient les plus nombreux représentant respectivement 46,28 (CGI), 41,41 (CESEH) et 48,14 % (CSM).
Parmi les enfants présents dans les centres specialisés à Abidjan, 57,12 % étaient de sexe masculin, avec un sex-ratio (M/F) de 1,33.
Concernant le niveau scolaire, 62,28 % des enfants étaient scolarisés (niveau préscolaire : 27,58 % ; niveau primaire : 30,78 % ; niveau secondaire : 3,91 %) et 37,72 % d’entre eux étaient non scolarisés.
Les causes du handicap des enfants suivis par ces centres sont présentées dans le Tableau 1 .
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