– More research about the social determinants of health in pediatric settings will be necessary to improve patient no-show rates for well-child visits, according to new data in the Annals of Family Medicine.
The healthcare industry is largely in agreement that access to primary care and well-child visits, especially early on in a child’s life, is essential for adequate healthcare, growth, and development. The American Academy of Pediatrics recommends 13 well-child visits before the age of six, with experts saying these visits will be good for attrition to recommended immunization schedules and providing guidance for new parents.
However, statistics show that children miss between 30 and 50 percent of those suggested early childhood well-visits, according to the research team, who hail from various pediatric departments at Virginia Commonwealth University.
“Poor, uninsured, and African American children miss a greater proportion of these visits compared with upper-income, privately insured, and white counterparts,” the investigators wrote. “Many states support safety-net practices to promote access. Despite these efforts, it is not fully understood why more disadvantaged patients miss a disproportionately larger share of well-child visits.”
Through a series of qualitative interviews with 17 caregivers and six family medicine or pediatric providers, the researchers were able to outline the importance and benefits of early childhood well-child visits, as well as the barriers that keep families from them.
Both caregivers and providers identified the issuing of important vaccines, detection of illness, and monitoring of child growth and development as the top benefits for early childhood wellness visits.
Respondents also said early childhood well-child visits were important for building a relationship between patient, family, and provider. Significantly, providers said attendance to early childhood visits increased the likelihood that patients would continue visiting the doctor for annual well-child visits.
But the respondents also recognized that it is not always easy for families to get to early childhood well-child visits. Transportation to the pediatrician and the ability for parents or caregivers to get time off work for a visit are both significant barriers to care. Financial stress compound those challenges.
“Caregivers and clinicians also discussed competing priorities, such as caring for young children, older children’s school schedules, and the scheduling of the caregivers’ own medical appointments,” the investigative team reported. “Clinicians also thought that caregivers may prioritize attending well-child visits in which vaccinations are typically given.”
Additionally, clinicians posited that immigration status and language barriers keep some patients from engaging in early childhood well-child visits. Spanish-speaking caregiver respondents corroborated those thoughts, saying they’d be more interested in attending well-child visits if they knew they’d be meeting with a Spanish-speaking clinician.
These results come as little surprise, as the medical and public health fields have long recognized the role the social determinants of health play in patient care access. However, few resources exist to help providers address these social challenges for their patients.
There may be some action to be taken across the healthcare industry, the researchers suggested.
Social services groups can provide unique assistance to families that have challenges with childcare or transportation to the pediatrician. In the clinic, better care coordination could make it easier for families to remain engaged in well-child visits. Finally, the payer industry can continue to embrace value-based care models in the pediatric setting, incentivizing a more holistic approach to patient care.
“Our findings suggest there is a need to further explore the potential relationship between well-child visit attendance and social determinants of health,” the researchers concluded. “Although the importance of social determinants of health has been known to the scientific community for some time, attempts to address these determinants have been limited.”
That all said, pushes to address social determinants of health in the pediatric setting can be difficult. It takes a significant level of patient trust in a provider to unveil some of the social challenges faced at home, even if parents or caregivers understand the impact these challenges can have on a child’s health or wellness.
According to an August 2019 survey from Public Agenda and United Hospital Fund, conversations about social determinants of health in pediatric settings must be undergirded by trust and empathy. Although parents are ready to discuss a child’s nutrition, education, and some behavioral issues, they are more reticent to discuss home life.
Specifically, parents or caregivers are nervous to discuss custody issues, neighborhood safety, school bullying, and environmental hazards during medical appointments. Parents are also concerned about discussing their own mental health with their child’s clinician, as well as domestic issues or legal issues.
Caregivers acknowledge that these factors could impact a child’s health in the future, but do not always see them as important to providers’ work.
Specifically, focus group participants said they feared being judged by their providers or discriminated against. Additionally, parents felt the pressure to outline a complicated issue during a short appointment slot and were nervous there wasn’t much their clinicians could do to help them solve the problem.
Most of all, parents were nervous they could be reported to child protective services if they mentioned a dire issue.
“Parents were afraid that if they shared information about their lives with their pediatrician they might be investigated or even lose their kids,” David Schleifer, PhD, vice president, director of research at Public Agenda, said in a statement. “Parents told us that physicians must build trust if they want parents to open up about their lives.”
Industry leaders do need to continue their work to screen for and address the social determinants of health in pediatric healthcare. However, efforts to do so must be met with respect, empathy, and trust between parent or caregiver and provider.