Parental Perceptions of Culturally Sensitive Care and Well-Child Visit Quality

Abstract

Objective:

Incorporating culturally sensitive care into well-child visits may help address pediatric preventive care disparities faced by racial and ethnic minorities, families with limited English proficiency, and immigrants. We explored parents’ perspectives about the extent to which their children’s pediatric care is culturally sensitive and potential associations between culturally sensitive care and well-child visit quality.

Methods:

We conducted cross-sectional surveys with parents attending a well-child visit for a child ages 3 to 48 months. To measure culturally sensitive care, we created a composite score by averaging 8 subscales from an adapted version of the Clinicians’ Cultural Sensitivity Survey. We assessed well-child visit quality through the Promoting Healthy Development Survey. Multivariate linear regression was used to understand associations between demographic characteristics and parent-reported culturally sensitive care. We used multivariate logistic regression to examine associations between culturally sensitive care and well-child visit quality.

Results:

Two hundred twelve parents (71% of those approached) completed the survey. Parents born abroad, compared with those born in the United States, reported significantly higher culturally sensitive care scores (+0.21; confidence interval [CI]: 0.004, 0.43). Haitian parents reported significantly lower culturally sensitive care scores compared with non-Hispanic white parents (−0.49; CI: −0.89, −0.09). Parent-reported culturally sensitive care was significantly associated with higher odds of well-child visit quality including receipt of anticipatory guidance (adjusted odds ratio: 2.68; CI: 1.62, 4.62) and overall well-child visit quality (adjusted odds ratio: 2.54; CI: 1.59, 4.22).

Conclusions:

Consistent with prior research of adult patients, this study demonstrates an association between parent-reported culturally sensitive care and well-child visit quality. Future research should explore best practices to integrating culturally sensitive care in pediatric preventive health care settings.

Providing children a regular source of high quality, comprehensive, and culturally sensitive preventive health care is a priority of the American Academy of Pediatrics (AAP).¹ However, disparities based on race, ethnicity, language, and nativity (ie, US born or immigrant) exist in access to high-quality well-child care. Compared with non-Hispanic white families, African American, Hispanic/Latino, Native American, and Asian families experience disparities in receipt of anticipatory guidance, primary care comprehensiveness, and parent-clinician communication.^2–4 Studies also have shown that parents with limited English proficiency and those born outside the United States report lower well-child care quality and receive recommended preventive care less often.^5–7 Therefore, it is critical to improve the provision of preventive care so it meets the needs of diverse and traditionally disadvantaged groups.

Providing culturally sensitive care during well-child visits is an important and potentially modifiable way to address preventive health care disparities.⁵ The AAP defines culturally sensitive care as “the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of all cultural distinctions leading to optimal health outcomes.”⁸ Two seminal publications from the National Academy of Medicine, Crossing the Quality Chasm and Unequal Treatment, describe cultural sensitivity as a key tenet of providing patient-centered care and reducing health-related racial and ethnic disparities.^9,10 Thus, it is important to engage various stakeholders to understand their perspectives about cultural sensitivity within the pediatric health care system and how culturally sensitive care may impact health care quality. To date, research on culturally sensitive care has primarily focused on the perspectives of adult patients and clinicians. In the adult literature, studies have shown that providing culturally sensitive care may increase patient satisfaction and reduce health care disparities faced by racial and ethnic minority groups.^11,12 Past studies have also highlighted the perspectives of clinicians who reported challenges in providing culturally sensitive care due to language barriers and disparate patient-clinician belief systems. However, participants in these studies also explained that clinicians can serve as cultural brokers, bridging the divide between patients and the health care system.^13,14

Less work has focused on understanding the impact of culturally sensitive care within pediatrics. Providing culturally sensitive care in the pediatric setting is unique, as the clinician-patient relationship is triadic (clinician-parent-patient) rather than dyadic. Additionally, with their unique focus on growth, development, and age-appropriate anticipatory guidance, pediatric preventive care visits have different goals than adult visits. Efforts to transform pediatric health care to be more culturally sensitive have prioritized provision of professional interpreter services.⁵ Although addressing language barriers is important, focusing exclusively on language represents only one component of delivering culturally sensitive pediatric health care. Brotanek et al⁵ argue that along with language sensitivity, normative cultural values (ie, beliefs and behaviors that a particular cultural group values in interpersonal interactions), clinicians practices, parental beliefs, and folk illnesses (ie, culturally constructed diagnostic categories) intersect to create culturally sensitive environments. A few studies have interviewed small samples of parents from different cultural groups to elicit their perspectives about culturally sensitive care in pediatric settings. These studies have shown that parents prefer clinicians with some knowledge about their cultural values, seek out care that meets their linguistic needs, and value the input of family when making medical decisions.^3,15,16 However, to our knowledge, no studies to date have surveyed a culturally diverse group of parents to examine their perceptions of the extent to which their children’s pediatric preventive care is culturally sensitive or how culturally sensitive care might be associated with well-child visit quality.

In this cross-sectional study, we surveyed parents to examine their perspectives about culturally sensitive pediatric health care. Our specific objectives included: 1) describing parent-reported culturally sensitive care during well-child visits; 2) comparing differences in parent-reported culturally sensitivity care based on race and ethnicity, English proficiency, and nativity; and 3) examining the association between parent-reported culturally sensitive care and well-child visit quality.

Method

Study Design and Participants

We conducted surveys in an urban, culturally diverse, academic pediatric primary care clinic situated within a safety net hospital. The clinic has approximately 12,000 visits per year and strives to employ a culturally and linguistically diverse team of clinicians. Interpreters are available for the majority of languages spoken by families seeking care at the clinic. Our institution’s Institutional Review Board approved all aspects of this study. Participants were parents or caregivers of at least 1 child aged 3 to 48 months who were accessing the clinic for a well-child visit for that child. Parents were eligible if they felt comfortable completing the survey in English, Haitian-Creole, or Spanish and if they were 18 years of age or older.

Participant Recruitment

Participants were recruited from the clinic during their child’s well-child visit using a convenience sampling approach. A trained bilingual research assistant (RA) used electronic medical records to identify potential families based on the child’s age (ie, 3–48 months) and reason for clinic visit (ie, a well-child visit). The RA approached potential participants either during or immediately after a well-child visit to ask if they would like to participate in the study and confirm eligibility. Visits did not interrupt clinical flow; if participants were approached during a visit, it was during a gap in clinical care (eg, if a family was waiting for immunizations). In terms of language eligibility, participants decided for themselves whether they felt comfortable completing the survey in one of the above languages. A consent statement was reviewed with the participant prior to data collection.

Measures

Culturally sensitive care:

To measure parent-reported culturally sensitive care, we adapted the Clinicians Cultural Sensitivity Survey (CCSS) to be relevant to a pediatric context. The original CCSS contains 14 subscales; further details about the CCSS can be found elsewhere.¹⁷ The adapted CCSS used in this study included 8 of the 14 subscales most aligned with Brotanek et al’s culturally sensitive care framework⁵: complementary and alternative medicine (CAM), causal attributions, family involvement, spirituality, clinician discrimination due to education, clinician discrimination due to racial and ethnic background, office staff discrimination due to racial and ethnic background, and sensitivity to language. These questions were adapted to be relevant for parents instead of adult patients. For example, instead of “How often did doctors ask if you use alternative medicine” we asked: “How often did your child’s doctors ask if your child uses alternative medicine?” We scored the CCSS by taking the mean of the items within each subscale, as described by Napoles et al.¹⁷

Well-child visit quality:

To measure well-child visit quality, we used the Promoting Healthy Development Survey (PHDS). Developed by the Child and Adolescent Health Measurement Initiative (CAHMI), the PHDS is a parent-completed questionnaire that examines well-child visit quality for children 3- to 48-month old. It is available in English and Spanish and has good reliability (Cronhbach’s alpha: .80) and validity in multiple populations including low-income and racially and ethnically diverse communities.^18,19 We included 6 quality domains from the PHDS most relevant to our research aims: 1) receipt of age-appropriate anticipatory guidance; 2) clinicians asking about developmental concerns; 3) clinicians addressing developmental concerns; 4) receipt of community-based resources; 5) helpfulness of care; and 6) impact of well-child care on parental confidence.²⁰ We also calculated the “got all care,” score which indicates whether a participant received all 6 domains of well-child visit quality. We scored each domain using instructions provided by CAHMI. First, each item was recoded to indicate whether the child’s clinician addressed the item. Next, we calculated the average proportion or mean of the items per domain. Finally, continuous measures were converted into dichotomous variables.²⁰

Demographics

We asked participants demographic questions about themselves and their child. Parent-focused demographics included age, gender, relationship to child, income, education, racial and ethnic background, English proficiency, and nativity (ie, US-born or immigrant). Racial and ethnic backgrounds were divided into: 1) black/African American; 2) African; 3) Asian; 4) white; 5) Hispanic/Latino; 6) Haitian; and 7) other. Participants could choose more than one racial and ethnic group, depending on how they identify. We aggregated black/African American and African due to sample size limitations. Participants were labeled as “English-proficient” if they reported speaking and understanding English “very well” and labeled as “limited English proficiency” if they reported speaking and understanding English less than “very well” (ie, “well,” “not well,” or “not at all”). Household income was divided into tertiles based on weekly pretax income: $≤230 (low), $231 to $550/wk (middle), and $≥551/wk high). Education was originally divided into 6 groups, which we aggregated into 3 due to sample size limitations: 1) high school graduate/GED or less; 2) some college or a 2-year degree; and 3) 4-year college graduate or more. Child-focused demographics included age, gender, and type of insurance.

Translation

For Spanish surveys, we used the PHDS and CCSS translations provided by the survey developers. A bilingual RA adjusted the original Spanish CCSS so it matched the adapted English CCSS. For Haitian-Creole surveys, we sent the English version of the survey to a professional translation service, which was then back-translated by a bilingual RA to ensure linguistic equivalence. Four participants piloted the Spanish and Haitian-Creole surveys prior to use.

Data Collection

After consenting, participants completed the 20-minute survey on a tablet in their language of choice. They were given the choice of completing the survey independently or having the survey read to them. After completion, participants were provided a 10-dollar gift card.

Data Preparation and Analysis

Data preparation:

First, surveys were compiled and reviewed for missing data. Item-level missingness was generally low (0%–8%), although 24% of surveys were missing income information. To reduce potential for nonresponse bias, hot deck imputation was conducted to account for missing data.²¹ All demographics included as covariates were converted into dummy variables. Finally, we ran Cronbach’s alpha analyses on seven of the 8 adapted CCSS subscales (1 subscale had only 1 item). All Cronbach’s alpha were >.8. Analyses were conducted using R version 3.3.

Composite score for parent-reported culturally sensitive care:

Due to the large number of subscales, we created a composite score for the culturally sensitive care variable by calculating the mean of the scores for the 8 culturally sensitive care subscales. Composite scores, which aggregate individual measures into a summary score, are widely used to facilitate measurement of health care quality and may provide a clearer picture of overall performance.²² Composite measures also reduce issues with multiple hypotheses testing, which may arise when study outcomes are numerous and a number of significant associations between individual outcomes and predictor variables are expected to be found by chance.²³ One potential pitfall with development of a composite score is if one averages across very poorly correlated or uncorrelated measures, the resulting composite may have low variability and mask individual differences. However, we found the subscales were moderately correlated and visual inspection of the resulting composite measure indicated good variability.

Data analysis:

We first calculated means and proportions to describe demographic data and examine parent-reported culturally sensitive care. Next, we employed linear regression models to separately test the associations between 3 demographic characteristics (race and ethnicity, English proficiency, and nativity) and parent-reported culturally sensitive care (using the composite score). In the adjusted models, we included covariates for parent’s education, income, and gender, and for child’s age.

Finally, we built adjusted logistic regression models to test the associations between parent-reported culturally sensitive care using the composite score and the 6 well-child visit quality domains, as well as the “got all care” score. Covariates included parent’s gender, race and ethnicity, English proficiency, nativity, education, income, and child’s age. These covariates were chosen as they have been shown in past literature to be associated with well-child visit quality.^2,4–6

Results

Participants’ Demographic Characteristics

Of the 299 individuals approached during recruitment, 212 agreed to participate (71% response rate). No demographic information was available for the 87 individuals who declined participation. The majority of participants were between the ages of 25 to 34 (50%), identified as female (81.1%), and attended some college (59.4%). Several racial and ethnic backgrounds were represented; the largest group identified as black, African American, or African (46.2%; Table 1).

Table 1.

Participant Demographics

Parents	N (%)
Age (y)
18–24	31 (14.6)
25–34	106 (50.0)
35 or older	75 (35.4)
Gender
Female	172 (81.1)
Male	37 (17.5)
Other	3 (1.4)
Relationship to child
Mother	169 (79.7)
Father	38 (17.9)
Other	5 (2.4)
Racial and ethnic background*
Black, African American, or African	98 (46.2)
Asian	13 (6.1)
White	26 (12.2)
Hispanic/Latino	42 (19.8)
Haitian	26 (12.2)
Other	13 (6.1)
Education
High school graduate/GED or less	86 (40.6)
Some college or 2-year degree	71 (33.5)
4-year college graduate or higher	55 (25.9)
Household weekly income
≤$230/wk	63 (29.7)
$231 –550/wk	67 (31.6)
≥551/wk	82 (38.7)
Place of birth
Born outside the United States	97 (45.8)
Born in the United States	115 (54.2)
English proficiency
Speaks and understands English “very well”	148 (69.8)
Speaks and understands English less than “very well”	64 (30.2)
Children
Age (mo)
3–9	93 (43.9)
10–18	69 (32.5)
19–48	50 (23.6)
Gender
Male	114 (53.8)
Female	98 (46.2)
Type of insurance
Medicaid	162 (76.4)
Private insurance	47 (22.2)
No insurance	0 (0)
Other	3 (1.4)

^*Participants were given the choice to select more than one racial and ethnic group.

Parent-Reported Culturally Sensitive Care

Participants generally reported receiving culturally sensitive care (Table 2). On a 5-point scale with 1 being the least culturally sensitive and 5 being the most, the mean composite score was 3.7 (standard deviation; SD: 0.7). The highest reported culturally sensitive care scores were in the discrimination-related domains, where few participants described experiencing discrimination due to education or race and ethnicity. Participants reported lower scores in the domains of clinicians asking about CAM (2.9; SD: 1.5), spiritual beliefs (2.3; SD: 1.7), language preferences (2.8; SD: 1.7), or including family during well-child visits (2.7; SD: 1.5).

Table 2.

Parent-Reported Culturally Sensitive Care for Total Sample

Culturally Sensitive Care Subscales*	Mean (SD)
Complementary and alternative medications	2.9 (1.5)
Causal attribution of health problem (ie, provider listening to what the parent thinks causes problems with their child’s health)	4.3 (1.2)
Family involvement	2.7 (1.5)
Spirituality	2.3 (1.7)
Discrimination due to education	4.8 (0.7)
Discrimination due to race and ethnicity (provider)	4.9 (0.6)
Discrimination due to race and ethnicity (staff)	4.9 (0.6)
Sensitivity to language needs	2.8 (1.7)
Composite score†	3.7 (0.7)

^*Each subscale scored on a scale of 1 to 5 (with 5 being the most culturally sensitive).

^†The mean of the 8 culturally sensitive care subscales.

Race and Ethnicity, English Proficiency, and Nativity and Parent-Reported Culturally Sensitive Care

Participants born outside of the United States reported higher culturally sensitivity care composite scores (+0.21; 95% confidence interval (CI): 0.004, 0.43) compared with those born in the United States. We also found that compared with non-Hispanic white participants, Haitian parents had lower culturally sensitive care composite scores (−0.49; CI: −0.89, −0.09). Participants identifying as other racial and ethnic minorities (ie, Black/African American/African, Hispanic/Latino, Asian, and other) did not report significantly different culturally sensitive care scores as compared with non-Hispanic white participants. Similarly, limited English proficiency participants did not report significantly different culturally sensitive care scores compared with participants who identify as English proficient (−0.02; CI: −0.25, 0.22).

Parent-Reported Culturally Sensitive Care and Well-Child Visit Quality

Adjusted logistic regressions showed that each 1-point increase in the culturally sensitive care composite score was associated with significantly higher odds of parent-reported receipt of age-appropriate anticipatory guidance that met their informational needs (adjusted odds ratio (aOR): 2.68; CI: 1.62, 4.62). Similarly, a 1-point increase in the culturally sensitive care composite score was associated with higher odds of parents finding their care helpful (aOR: 3.68; CI: 1.62, 9.35), stating their care improved their confidence (aOR: 2.62; CI: 1.28, 5.86), stating they received community-based resources (aOR: 2.47; CI: 1.25, 5.17), and reporting receipt of all 6 well-child visit quality metrics (the “got all care score”; aOR: 2.54; CI: 1.59, 4.22). See Table 3 for unadjusted and adjusted logistic regression analyses.

Table 3.

Odds of Perceived High-Quality Well-Child Care Based on the Parent-Reported Culturally Sensitive Care Composite Score^†

Outcome	OR(CI)	Adjusted OR (Cl)‡
Provision of information about resources in the community for parents	1.41 (0.81,2.53)	2.47 (1.25,5.17)*
Ask about parental concerns about their child’s learning, development, and behavior	1.51 (0.93,2.53)	1.72 (0.97,3.15)
Address parental concerns	1.47 (0.79,2.86)	1.46 (0.73,3.06)
Anticipatory guidance and parental education	1.89 (1.25,2.93)**	2.68 (1.62,4.62)***
Helpfulness of care provided	2.61 (1.30,5.68)*	3.68 (1.62,9.35)**
Effect of care provided on parental confidence	2.23 (1.18,4.52)*	2.62 (1.28,5.86)*
Received all 6 of the above well-child visit quality indicators (“got all care” score)	2.07 (1.38,3.16)***	2.54 (1.59,4.22)***

^*P < .05.

^**P < .01.

^***P < .001.

^†The culturally sensitive care composite score is the mean of the 8 culturally sensitive care subscales. The composite score range is from 1 to 5, with 5 being the most culturally sensitive.

^‡Adjusted for parental education, gender, income, race and ethnicity, nativity, English proficiency, and child’s age.

Discussion

To our knowledge, this is the first study to examine parents’ perspectives about receipt of culturally sensitive care during well-child visits, adding to a scant but growing literature base. Participants generally reported receiving culturally sensitive care with the highest scores in the domains of not feeling discriminated against by clinicians and office staff and the lowest in clinicians asking about CAM and spirituality, determining language preferences, and including families in care plans. Participants born outside the United States were more likely to report receiving culturally sensitive care; those identifying as Haitian reported receiving care that was less culturally sensitive. Parent-reported culturally sensitive care was associated with multiple well-child visit quality outcomes.

Participants reported less culturally sensitive care in the domain of clinicians asking about CAM during well-child visits. Past studies of different cultural groups have highlighted patients’ interest in discussing CAM during primary care visits.^3,24,25 Parents are more likely to disclose use of CAM if clinicians specifically inquire about it.²⁴ However, a study of pediatric residents showed that only 38% of participants routinely asked their patients about use of CAM and many felt they lacked proper training about how best to incorporate CAM into their practices.²⁵ The results of the current study add to prior literature and indicate the need for further training for pediatric clinicians on how to ask about CAM during well-child visits.

Compared with parents born in the United States, immigrant parents were more likely to report receiving culturally sensitive care. This differs from past literature which has found that immigrant families generally experience less culturally sensitive care. For example, researchers studying the experiences of adult immigrant patients found they may face discrimination and cultural conflicts with clinicians.^26,27 Additionally, 2 reviews, one focused on health care quality for children with special health care needs²⁸ and the other on children diagnosed with autism,²⁹ found that immigrant children face barriers to accessing high quality, culturally sensitive health care. Pediatric clinicians may also perceive that immigrant families need more culturally sensitive care compared with US-born parents, leading to immigrant parents reporting higher receipt of culturally sensitive care. Alternatively, our findings may reflect the differences between well-child visits in the United States versus other countries; for example, past work describes how Asian immigrant parents noted well-child visits to be different than pediatric care they remembered from their countries of origin.³ Therefore, it is possible that immigrant families have different expectations regarding culturally sensitive care as compared with parents born in the United States.

Haitian parents were less likely than non-Hispanic white parents to describe their care as culturally sensitive. Scant research on the provision of culturally sensitive care in pediatric health care settings has specifically examined the perspectives of the Haitian immigrant community, whose population has grown 200% in the United States since 1990.³⁰ Studies of adult patients have shown that Haitian patients may not trust their clinicians,³¹ may feel that their clinician does not understand their cultural values,³² and face barriers accessing interpreters.³² Future research should consider designing interventions in pediatric health care settings specifically for Haitian families. Haitian participants are generally reported under the “black or African American” category in literature on health disparities.³³ We found that Haitian participants, as compared with white participants, reported less culturally sensitive care. The same pattern did not emerge for participants identifying as black, African American, or African. These results may highlight the importance of disaggregating racial and ethnic groups to better understand intragroup disparities.³⁴

This is the first study to show that parent-reported culturally sensitive care is associated with well-child visit quality. The majority of past research on culturally sensitive care within the pediatric preventive care setting has examined how patient-clinician racial, ethnic, and linguistic concordance impacts well-child visit quality. For example, Boudreau et al found that Hispanic/Latino parents with a language-concordant pediatric clinician did not report higher well-child visit quality as compared with parents with language-discordant clinicians.¹⁸ Similarly, Stevens et al found that while racial and ethnic minority parents reported worse well-child visit quality as compared with non-Hispanic white parents, there was no association between parent-clinician racial and ethnic concordance and parent-reported well-child visit quality.⁴ The differences between the results of the current study and past research may indicate that well-child visit quality is not completely driven by clinicians’ cultural identities but also by questions asked during visits that show curiosity and interest in parents’ cultural values. Future research using matched parent-clinician data is needed to further explore this hypothesis.

We recognize that there are limitations to this study. Culturally sensitive care is nuanced; it is possible there are other forms of culturally sensitive care that we did not address. The CCSS was developed based on feedback from adults of multiple racial and ethnic groups and validated using an older Latino population.¹⁷ We adapted the CCSS to be relevant to a pediatric health care setting. Future research should attempt to validate the CCSS for the pediatric population. We also recognize the limitation in shortening the number of CCSS subscales, which we did to ensure the study was feasible to distribute in a primary care clinic.

The clinic where this study took place strives to employ a linguistically and culturally diverse group of clinicians; however, we were unable to collect specific demographic information about clinicians as the goal of this study was focused on parents’ perspectives. Due to sample size limitations, we aggregated subgroups for certain demographic covariates (eg, educational attainment) into fewer categories. Additionally, sample size limitations precluded us from conducting additional subgroup analyses (eg, differences in participant-reported culturally sensitive care between Asian immigrants and US-born Asians). We recognize that results from this convenience sample may not generalize to all clinic patients. Finally, we recognize limitations inherent to cross-cultural survey research; past literature has shown, for example, that survey response patterns may change based on racial and ethnic group, language preferences, and acculturation patterns.³⁵

Conclusions and Implications

The results of this study have important research and clinical implications. Future studies measuring culturally sensitive care and well-child visit quality may consider nonsurvey methods, such as observing parent-clinician interactions and include larger sample sizes to better understand associations between cultural background (eg, race and ethnicity, nativity) and culturally sensitive care. Similar work should be conducted in different pediatric health care settings, including the emergency room and inpatient settings. This study focused on the perspectives of parents with young children. Future research should consider exploring the perspectives of older children and adolescents regarding culturally sensitive care. This is particularly important as children, especially those whose parents were born outside the United States, may espouse different cultural values than their parents, and thus may have unique perspectives on integrating culturally sensitive care into pediatric settings.³⁶ Future work should also explore pediatric clinicians’ perspectives about culturally sensitive care and examine matched parent-clinician data. Development and validation of a multidimensional pediatric culturally sensitive care measure is indicated. Measures should attempt to distinguish whether culturally sensitive care is being providing in situations where clinicians believe a family needs culturally sensitive care versus when families actually prioritize culturally sensitive care. Our study examined cultural sensitivity at the clinician level; future research may consider exploring clinic, hospital, or health care system-level culturally sensitive care indicators. Finally, these results have implications for clinical practice, especially as considerable attention has been given to optimizing pediatric preventive care to meet the needs of diverse communities.³⁷ Incorporating culturally sensitive care into the pediatric medical home may be a modifiable target when considering well-child visit redesign.

What’s New.

Using cross-sectional survey data, we explored parents’ perceptions about culturally sensitive care during pediatric well-child visits. Study results describe differences in parent-reported culturally sensitive care based on demographic factors and show an association between culturally sensitive care and well-child visit quality.