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Parental Perceptions of Well-Child Care Visits in an Inner-city Clinic
Sharon Busey, MD;
Timothy R. Schum, MD;
John R. Meurer, MD
Arch Pediatr Adolesc Med. 2002;156:62-66.
ABSTRACT
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Objectives To assess parental perceptions of the importance of well-child care
(WCC) in an inner-city clinic and to determine what type and format of information
parents would like to obtain at WCC visits.
Methods A convenience sample of parents accompanying a child aged 12 years or
younger attending an inner-city pediatric teaching clinic completed self-administered
written surveys. Parents ranked the importance of WCC overall, as well as
its various components, using Likert scales. Parents also responded to checklist-style
questions to indicate selected topics they would like to receive more information
about and the format of information they preferred (written, talking to the
physician, or videotapes in the waiting room).
Results A total of 239 parents completed surveys. Overall they believed WCC
was important (91% responded "extremely important" or "very important"). The
individual WCC components ranked most important by parents were immunizations,
growth and development issues, and the opportunity to discuss behavior or
other concerns. The topics of information requested most frequently were how
to help their child learn healthy eating habits (55%), how to help their child
do well in school (53%), and how to keep their child safe outside of their
home (49%). Written information was the format most frequently preferred (65%)
by parents for receiving information.
Conclusions Parents of inner-city children consider WCC important. They want to
hear about child health–related issues and prefer a written format.
This knowledge can guide health care providers and educators during WCC visits
and while teaching.
INTRODUCTION
THE IMPORTANCE of preventive pediatrics has been the subject of frequent
attention and analysis over the last decade, especially in light of the "new
morbidity" issues facing our country's children and families today. While
medical progress and technology have markedly reduced the risk disease poses
to children today, medical problems have been supplanted by a broad spectrum
of psychosocial problems (ie, learning difficulties, violence, and behavioral
and emotional disorders) that threaten children's success and achievements
regarding education, mental health, and personal safety.1-2
Children living in poverty stand to potentially benefit the most from preventive
care because they are at greater risk for both medical and psychosocial problems
than their more affluent peers.3
Primary care pediatricians are in an optimal position to identify and
implement intervention for the problems affecting children today, particularly
in the context of the well-child care (WCC) visit. Well-child care visits
are considered an ideal opportunity to address preventive care issues, such
as age-appropriate anticipatory guidance, immunizations, and screening for
problems such as anemia and lead poisoning.4-5
Anticipatory guidance regarding home safety (eg, to increase smoke alarm use
and decrease risk of falls), bicycle helmet use, and seat belts and car seats
have all produced measurable differences in parent's use of these measures
and reductions in injury.6-7 Parents
are also interested in discussing topics such as infant crying and sleep patterns
as well as psychosocial issues with their pediatrician, and the WCC visit
is an ideal opportunity for such discussions.1, 8-9
Yet, despite the importance attributed it, WCC remains underused in
many settings, especially in inner-city clinics.10-12
Subsequently, the well-being of the family and child suffer adversely as a
result of these missed opportunities in preventive care. Clinic efficiency
and, in many settings, resident education also suffer as a result of this
underuse of care. Even when these patients are seen, the time spent during
a WCC visit is often inadequate.13 The goal
of providing complete and effective anticipatory guidance on a variety of
topics is difficult under the most ideal circumstances in any clinic because
of time constraints. Chronic medical issues often need to be revisited and
parents frequently bring new concerns to be addressed at WCC visits. Busy
clinic schedules, limited facility space, and financial pressures can further
compromise the time devoted to preventive care issues.
Efforts to analyze this underuse of care have identified factors affecting
parental compliance with recommended WCC visits, including late prenatal care,
insurance status, maternal socioeconomic factors, and access factors.12, 14-18
Parental perceptions and expectations of WCC have also been examined.19-20 While the influence of socioeconomic
factors on parental compliance with WCC visits has been addressed, limited
information is available specifically regarding the perceptions and expectations
of parents of inner-city children. The objectives of this study were 3-fold:
(1) to learn how inner-city parents perceive WCC visits; (2) to learn what
information parents would like to receive (ie, nutritional advice, safety
counseling, or behavioral tips; and (3) to provide knowledge regarding what
type of information format (written, spoken, or videotaped) parents would
most prefer to receive this information.
PARTICIPANTS AND METHODS
Study participants were drawn from a convenience sample of parents bringing
a child to a visit at an inner-city pediatric resident teaching clinic. Surveys
were collected from October 1, 1997, through December 19, 1997. The survey
was limited to English-speaking patients only. Because of the anonymous nature
of the surveys, the study was deemed exempt from further review by the Research
and Publication Committee of the Medical College of Wisconsin Human Rights
Review Board, Milwaukee.
Parents bringing a child younger than 12 years to the clinic were targeted
for the study. Adolescent patients were excluded because the content of WCC
visits for adolescents differs significantly from the content of WCC visits
for younger children. The surveys were presented to the parent in the clinic
examining room by a medical student or resident after completion of the medical
history and physical examination. The presenter explained that we were interested
in knowing how parents felt about their child's care and what elements of
their child's care were important to them. Parents were asked to complete
the short self-administered written survey after the student or resident left
the examining room to discuss the patient with an attending physician. The
surveys were then collected before the patient left the clinic.
A total of 268 completed surveys were obtained. Only surveys completed
by a natural parent (n = 239) were included in the analysis. Surveys completed
by grandparents, stepparents, or foster parents were excluded from the analysis.
The survey gathered demographic data using standardized questions from
the Child Health Questionnaire, a survey instrument designed to understand
the daily functioning and well-being of children and their families.21 Parents rated the importance of WCC and its components
(eg, immunizations, information about growth and development, and others)
using a 5-point Likert scale with responses ranging from "extremely important"
(1) to "not very important" (5). Finally, a simple checklist was used to gather
information regarding the type and format of information parents would prefer.
The survey forms did not contain or request any identifying information that
could be used to link a parent or patient with their survey responses.
Frequency responses for all questions were determined. Data analyses
were performed to determine whether parents of children of different ages
had different perceptions or requests regarding their WCC. Parent responses
were grouped according to whether they had only preschool-aged children (<5
years old) or at least 1 school-aged child ( 5 years old). The Likert scale
responses were condensed into dichotomous variables—"very important"
and "less important." (Very important included the 2 Likert scale responses
indicating highest importance [1 and 2], and less important the 3 remaining
responses.) Cochran-Mantel-Haenszel tests were used to compare parental perceptions
regarding WCC and its components between parents who had only preschool-aged
children and parents who had at least 1 school-aged child. Prevalence odds
ratio were used to determine whether parent requests for different topics
of information differed significantly depending on whether the parents had
only preschool-aged children or at least 1 school-aged child. Statistical
significance was set at P<.05. Data analyses were
performed by the Medical College of Wisconsin Department of Biostatistics
using Statistical Analysis System (SAS Institute, Cary, NC). Responses to
the survey question inquiring whether a parent knew if their child was due
for a WCC visit (question 4) were discarded after analysis because the anonymous
nature of the survey prevented verification of responses.
RESULTS
DEMOGRAPHICS
A total of 239 natural parents, primarily mothers (92%), completed the
surveys. Most of the surveyed parents were African American (84%). The sample
was considered representative of the clinic population that is composed of
82% African Americans, 8% Hispanics, 7% whites, and 3% of unknown race. Approximately
85% of our clinic population is enrolled in Medicaid or a Medicaid health
maintenance organization. Twenty-nine surveys were completed by caretakers
of a relationship other than a natural parent (ie, foster parents, stepparents,
legal guardian, or other); these surveys were excluded from the analysis. Table 1 lists parent demographic information
and the age ranges of their children.
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Table 1. Characteristics of 239 Surveyed Parents and Their Children
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PERCEPTIONS OF WCC
Parents rated the importance of WCC visits overall and of 5 separate
components of WCC (Table 2). Overall,
87% of parents believed WCC was extremely important. Parents also indicated
that all of the individual components of WCC were important to them. The most
highly ranked WCC components were "shots" and "Making sure your child is growing
and developing normally"; 91% of parents ranked both components as extremely
important.
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Table 2. Two Hundred Thirty-nine Parent Responses Regarding the Importance
of Well-Child Care and Its Components*
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Parents were asked to select as many choices as applied from a list
of 6 topics about which they would like to obtain more information (Table 3). The most frequently requested
topics were "How to help my child learn healthy eating habits" (55%); "How
to help my child do well in school" (53%); and "How to keep my child safe
outside of my home" (49%). Parents were also given the opportunity to write
in other responses to this question. Eighteen parents wrote in responses,
mostly dealing with development, behavior, and the physical and mental health
of their child.
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Table 3. Topics of Information Requested by Parents and the Difference
in Requests Between Parents of Only Preschool-Aged Children vs Parents Who
Had at Least 1 School-Aged Child*
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No statistically significant difference regarding the overall importance
of WCC occurred between parents of only preschool-aged children vs parents
of at least 1 school-aged child. The only statistically significant difference
regarding parental perceptions of the components of WCC was that parents who
only had preschool-aged children considered obtaining laboratory studies to
check their child's blood cell count and lead level more important than did
parents who had a school-aged child (73% vs 21%) (Table 2). Parents of school-aged children were more likely than
parents of only preschool-aged children to request information about how to
protect their children from violence (28% vs 12%), how to keep their child
safe outside of their home (33% vs 16%), and how to help their child do well
in school (38% vs 15%) (Table 3), respectively.
FORMAT OF INFORMATION
Parents were asked to select as many choices as applied from a list
of 3 choices regarding what format they preferred for receiving information
about WCC topics. The choices included "written information," "by talking
with the doctor," and "videotapes (in the waiting room)." The most frequently
preferred format was written information (65%, n = 156). The second most preferred
format was talking with the physician (42%, n = 101), followed by videotapes
(26%, n = 23) in the waiting room.
PARENTAL COMMENTS
Parents were invited to write comments on the back of the survey form.
Only 10 parents responded; their comments primarily had to do with the level
of satisfaction with the care they received at our clinic.
COMMENT
Over the last few decades pediatric WCC has evolved from a preponderantly
disease-oriented focus to include a larger component of preventive care. The
overall concept of WCC continues to be plagued by limited measurable outcomes
indicating its effectiveness and success; this limitation is even more concerning
in this era of preventive care. Identifying what parents think is important
and what contributes to their satisfaction is worthwhile as a means of identifying
needs and opportunities for intervention.
Parents of inner-city children consider WCC important, regardless of
their child's age. They are interested in learning about topics pertinent
to their child's health, and they prefer a written format for obtaining information.
Parents of school-aged children, in particular, are interested in receiving
information about topics such as protecting their child from violence, keeping
their child safe outside of their home, and helping their child do well in
school.
Previous studies have documented that parents are interested in receiving
more information about psychosocial issues from their physicians. Young et
al20 conducted a large national telephone survey
of more than 2000 parents of children younger than 3 years. Despite having
a study population that was demographically different than ours (preponderantly
married, nonteenaged parents with a median annual income of $30 000),
the results were similar because most parents were interested in receiving
more information about one or more areas of child rearing (eg, discipline
and how to encourage learning). Cheng et al19
interviewed 200 mothers of young children who attended a pediatric health
maintenance organization clinic about their expectations and perceptions of
their WCC. The mothers in this study believed that the physical aspects of
health were more important than the psychosocial issues. The authors concluded
that, given the current emphasis on preventive issues, these responses may
be an indicator that we, as physicians, are not doing our job effectively.
The mothers of lower socioeconomic status in this study felt more strongly
than the mothers of higher socioeconomic status that medical goals were the
most important components of WCC and that psychosocial issues were unimportant.
Our study results resembled these results in that our group of inner-city
parents rated immunizations as extremely important more frequently than any
other component of WCC. However, our respondents also indicated that the nonmedical
components of WCC were also very important to them. Our study results are
also consistent with previous research that indicates parents consider their
physicians to be an important source of parenting information and that parents
have concerns regarding an increasing number of psychosocial issues.8-9,19
Our parents' preference for written information is intriguing. Written
information is generally accepted as an effective and simple way to distribute
information to parents.22 However, studies
of patient education materials have shown that readability levels do not necessarily
correspond to comprehension levels, and care must be taken to provide patient
materials that will be understood to be effective.23-24
Several limitations regarding our study must be acknowledged. First,
by administering the survey in the clinic, we selected a population that uses
the clinic and may be biased toward perceiving children's health care as more
important than the general population. Second, many of the parents surveyed
may have had children spanning a wide age range. Third, the nature of the
survey tool precluded determination of how the responses of those parents
may have varied based on the age group they were considering when they answered
the question. For example, we had no way of determining if they were answering
questions with their 1-year-old child or their 11-year-old child in mind.
Fourth, because of the limited nature of the study, we chose not to survey
grandparents of our patients. This exclusion may have prevented us from gaining
valuable information as many families in the inner-city are 3-generational
with grandparents often being the primary caretaker of their grandchildren.
Finally, we must acknowledge the possibility that the results of our study
could be affected by surveying parents who are not functioning as the primary
caretaker of their child.
Other limitations include, as with any use of the Likert scale, the
possibility of a lack of internal consistency between each level of response.
Also, this study relied solely on self-reported information. No other method
was used to corroborate or verify responses. The use of close-ended questions
possibly limited the full range of parental responses. We attempted to overcome
this limitation by inviting parents to write comments. However, the response
was limited. The inability to validate responses and the small size of the
study limit the degree to which the findings can be generalized to a broader
population of inner-city parents. Although the survey population seemed representative
of our overall clinic population, larger scale studies are needed to prove
generalization to larger populations.
CONCLUSIONS
Children of lower socioeconomic status face a double jeopardy: they
are less likely to use preventive health care opportunities than children
of higher socioeconomic status, and they are at risk for more problems related
to their poverty.3 The challenge to physicians
caring for these children is to take maximum advantage of the limited opportunities
available to determine what a parent wants to know and offer information regarding
that topic. In addition, physicians need to continue to educate parents about
those topics that have been shown to positively influence the health and safety
of children. Obstacles to WCC need to continue to be investigated since parents
continue to underuse it despite their indication that they believe it is important.
Written information may be a method to be used or to supplement the physician
encounter, although care must be taken to ensure that it is of a complexity
and reading level that will be acceptable and helpful to the parent.
| What This Study Adds
Well-child care visits provide an opportunity to identify problems and
provide intervention for children. Children living in poverty are known to
be at greater risk for medical and psychosocial problems than their wealthier
counterparts. However, limited information is available regarding how parents
of impoverished children perceive WCC and what they expect from it.
This study revealed that parents of inner-city children consider WCC
important, and they prefer a written format for learning about topics pertinent
to their child's health. Parents of school-aged children in particular are
interested in learning about how to protect their children from violence,
how to keep them safe outside the home, and how to help them do well in school.
Identifying what parents perceive as important aids in identifying the needs
of children and providing intervention.
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AUTHOR INFORMATION
Accepted for publication August 20, 2001.
This study was supported by a grant from the Children's Hospital Foundation,
Milwaukee, Wis (Dr Busey).
Presented as a poster at the annual meeting of the American Pediatric
Society/Society for Pediatric Research, New Orleans, La, May 4, 1998.
We offer special thanks to Shelly Penberthy, RN, and the Medical College
of Wisconsin pediatric residents and medical students for their help and cooperation
with administration of the surveys.
Corresponding author and reprints: Sharon Busey, MD, Downtown Health
Center, 1020 N 12th St, Milwaukee, WI 53233 (e-mail: busey{at}mcw.edu).
From the Department of Pediatrics, Medical College of Wisconsin, Milwaukee.
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