Parental Perceptions of Well-Child Care Visits in an Inner-city Clinic FREE

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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@mcw.edu).

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.