Time Spent at Well-Child Care Visits for English- and Spanish-Speaking Parents

Abstract

Objective:

To measure duration of well-child care (WCC) visits at 2 federally qualified health centers (FQHCs), across 10 clinic sites, and determine if differences exist in visit duration for English- and Spanish-speaking parents.

Methods:

Upon arrival to their child’s 2- to 24-month well visit, a research team member followed families throughout their visit noting start and end times for a series of 5 WCC visit tasks. The average time to complete each visit task for the entire sample was then calculated. Mann-Whitney U tests were run to determine if task completion time differed significantly between English- and Spanish-speaking parents.

Results:

The total sample included 199 parents of infants and children between 2 and 24 months old. Over one third of the sample spoke Spanish as their primary language (37%). The average visit time was 77 minutes (standard deviation [SD] = 48). Median time spent with the clinician was 14 minutes (SD = 5). Clinician visit time was significantly different U = 2608, P < .001, r = 0.38 between English- (median = 15 minutes) and Spanish (median = 11 minutes)-speaking parents. No other significant differences were identified.

Discussion:

Our findings align with previous studies showing the average time spent with a clinician during a WCC visit was 15 minutes. Further, the average time with a clinician was less for Spanish-speaking parents. With limited visit length to address child and family concerns, re-designing the structure and duration of WCC visits is critical to best meet the needs of families living in poverty, and may ensure that Spanish-speaking parents receive appropriate guidance and support without time limitations.

Well-child care (WCC) visits during early childhood provide a unique opportunity to address not only comprehensive child health preventive care needs, but also many needs relating to the social determinants of health for entire families.^1,2 For many families of young children, interaction with primary care settings at WCC visits is the primary mechanism for screening and referral to other community-based services such as housing and parent employment support.³ This opportunity to intervene is particularly important for families living in poverty as early childhood health and experiences set a foundation for health and social circumstances in later life.⁴ Unfortunately, many families do not receive these services, due in part to the limited time that parents have with their primary care team at a typical preventive care visit.⁵ While the average duration of WCC visits was found to be just 15 to 20 minutes a decade ago,⁶ no recent studies have examined WCC visit duration for Medicaid-insured populations that often have greater needs. To address this gap, we measured WCC visit duration for a Medicaid-insured population of children served by federally qualified health centers (FQHCs). We also assessed whether differences exist for Spanish and English-primary language families because 13.5% of the US population speak Spanish at home,⁷ and 84% of FQHCs nationally serve patients with limited English proficiency.⁸ With knowledge of current visit time structures, we can better design WCC service interventions that afford appropriate time to address the comprehensive preventive care needs of families living in poverty and ensure Spanish-speaking families are receiving equitable care.

Methods

We studied preventive care visit duration at 10 primary care clinics from 2 FQHCs, across 10 separate clinic sites, in the Los Angeles, California and Seattle Washington areas. The Seattle Children’s Research Institutional Review Board approved the study. We invited and enrolled parents with a primary language of English or Spanish attending a clinic for a child’s 2- to 24-month WCC visit to participate in a research study to observe their visit. Parents who did not speak English or Spanish were excluded. A trained research assistant accompanied the parent throughout the duration of their child’s visit and used the stopwatch feature of a mobile device to measure the duration of 5-visit WCC elements:

1. Check-In: time at reception, and obtaining any paperwork

2. Paperwork Completion: time filling out paperwork during check-in and other parts of visit

3. Triage: rooming, vitals, and measurements by medical assistant

4. Clinician Visit: direct interaction with the provider, including greetings, history taking, physical examination, and discussions related to anticipatory guidance, developmental assessments, and psychosocial needs

5. Procedures: for example, vaccinations, anemia screening

We documented the length of the entire visit, from arrival at the front desk to completion of check-out. We measured wait times between triage, clinician visit, and procedures.

Analysis

We calculated median time for each preventive care visit and visit task for the full sample, and by visit language (English/Spanish). We used Mann-Whitney U tests to compare task times by visit language. We conducted all analyses using SPSS 19 (IBM Corp, Armonk, NY).

Results

One hundred ninety-nine parents of children 2 to 24 months of age arriving for a well-visit were enrolled across 10 clinical sites. Most respondents (67%) had a household income <$35,000 and another 24% made between $35,000 and $69,999. Nearly a quarter (23%) of respondents had less than a high school diploma, 38% had a high school diploma, and 29% had a 2-year degree or some college. Over half (52.3%) were born outside of the United States; over a third (36.7%) used Spanish as their primary language, while the remaining respondents spoke English. Most (86.5%) Spanish-speaking parents had a visit with a bilingual provider, and thus did not have an interpreter during the visit. For the minority of parents who saw a provider who did not speak Spanish, a Spanish-language interpreter was used. Finally, 96% of children were insured through Medicaid. Participant demographics are in Table 1.

Table 1.

Participant Characteristics (N = 199)

	N (%)
Primary household language
English	126 (63)
Spanish	73 (37)
Parent country of birth
United States	95 (48)
Other	103 (52)
Parent education level
Less than high school	46 (23)
High school diploma/GED	75 (38)
2-year degree/some college	57 (29)
4-year degree or greater	20 (10)
Household income
<$10,000	28 (14)
$10,000–$19,999	40 (21)
$20,000–$34,999	64 (33)
$35,000–$69,999	46 (24)
$70,000 or more	16 (8)
Child race and ethnicity
American Indian or Alaskan Native	1 (1)
Asian	5 (2)
Black or African American	7 (3)
Latinx or Hispanic	125 (63)
Native Hawaiian or Pacific Islander	6 (3)
White	19 (10)
Multiracial	32 (16)
Other	4 (2)
Child insurance type
Medicaid	190 (95)
Other	9 (5)

GED indicates Test of General Educational Development.

Table 2 shows the median duration of each visit task and the 25th and 75th percentiles. The median duration of each visit component was: total visit, 71 minutes; check-in, 11 minutes; paperwork, 10 minutes; triage, 8 minutes; clinician visit, 14 minutes; follow-up procedures, 5 minutes. Clinician visit duration was significantly shorter (U = 2608, P < .001, r = 0.38) for Spanish (median = 11) compared with English-language visits (median = 15); there were no significant differences in duration of other preventive care visit tasks between these 2 groups. Among parents of Latinx children only, the gap in clinician visit duration between Spanish- and English-language visits remained (14 vs 12 minutes, P < .001).

Table 2.

Length of Well-Child Care Visit Tasks in Minutes

Visit Task	Full Sample Percentiles			English Sample Percentiles			Spanish Sample Percentiles
	25th	50th	75th	25th	50th	75th	25th	50th	75th
Check-in	6.0	11.0	19.0	6.5	11.0	17.0	6.0	10.0	24.5
Paperwork completion	4.0	10.0	19.0	5.0	11.0	19.0	3.0	8.0	20.0
Triage	5.0	8.0	11.0	5.5	9.0	11.5	5.0	7.5	10.0
Wait	6.0	11.5	18.0	5.3	10.5	18.0	6.0	13.0	18.0
Clinician visit	10.0	14.0	18.0	12.0	15.0	20.0	9.0	11.0	15.0
Wait	4.0	7.0	12.0	4.0	7.0	12.0	4.0	7.0	12.0
Follow-up procedures	3.0	5.0	9.0	3.0	5.0	9.0	2.0	4.0	7.8
Total visit	56.0	71.0	88.0	59.0	74.0	88.0	50.5	67.0	87.5

Discussion

While total time spent in the clinic for a WCC visit is more than an hour in duration, clinician time is short (≤15 minutes), and significantly shorter for Spanish-speaking parents compared with English-speaking parents. Previous research has identified that parents of Latinx children, particularly those who use a language other than English, are more likely to report unmet needs and to report that their provider did not spend enough time with them or show sensitivity to their families’ values and customs, compared with white or English-language families.^9,10 Future research should investigate causes of these inequities, including structural racism that leads to limited availability of bilingual/bicultural Latinx primary care providers and interpreters. Such research may lead to interventions to address this inequity in primary care.¹¹ Although many of the Spanish-language visits were conducted with bilingual providers, most were non-native speakers, and the clinics did not utilize a formal certification process; it is possible that suboptimal language abilities of these providers could have reduced their engagement in conversational skills in rapport-building and more detailed discussions.¹²

Additionally, our findings highlight the need for WCC care delivery interventions to optimize the use of the entire visit time to meet preventive care needs. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents 4th edition¹³ outlines the preventive care services that specifically seek to intervene on the entire social and environmental circumstance of families. However, many clinicians report a lack of confidence in their ability to address social needs of children and families.³ With limited visit length and uncertainty on how to discuss and address family social needs, the re-designing of WCC visit structures is needed to best meet the needs of families living in poverty.¹⁴

Drawing on the strengths of community health worker models, potential interventions can include team-based approaches to care that incorporate community health workers into the WCC team to provide preventive care services, health education, social needs screening, and anticipatory guidance to families.¹⁵ At the time of the study, the clinics did not include community health workers in WCC, but incorporating nonclinicians with similar lived experiences and shared language as part of a WCC team can afford greater opportunities for culturally congruent counseling^16-18 with the potential for more comprehensive coverage of topics that clinicians report uncertainty with. Further, along with the introduction of a community health worker, innovations to make use of wait times, previsit collection of information and paperwork, and community partnerships to address preventive care needs may further optimize access and utilization of services for low-income families.^14,19

What’s New.

English-speaking parents spent 15 minutes with their child’s clinician; Spanish-speaking parents spent 11 minutes. Introducing community health workers as part of the clinic team may enhance receipt of well-child care services by increasing visit time and improve linguist congruency.