Addressing psychosocial topics in group well-child care: a multi-method study with immigrant Latino families

Abstract

Objective:

Group Well-Child Care (GWCC) has been described as providing an opportunity to enhance well-being for vulnerable families experiencing psychosocial challenges. We sought to explore benefits and challenges to the identification and management of psychosocial concerns in Group Well-Child Care (GWCC) with immigrant Latino families.

Methods:

We conducted a case study of GWCC at an urban academic general pediatric clinic serving predominantly Limited English Proficiency Latino families, combining visit observations, interviews, and surveys with Spanish-speaking mothers participating in GWCC, and interviews with providers delivering GWCC. We used an adapted framework approach to qualitative data analysis.

Results:

42 mothers and 9 providers participated in the study; a purposefully selected subset of 17 mothers were interviewed, all providers were interviewed. Mothers and providers identified both benefits and drawbacks to the structure and care processes in GWCC. The longer total visit time facilitated screening and education around psychosocial topics such as postpartum depression but made participation challenging for some families. Providers expressed concerns about the effects of shorter one-on-one time on rapport-building; most mothers did not express similar concerns. Mothers valued the opportunity to make social connections and to learn from the lived experiences of their peers. Discussions about psychosocial topics were seen as valuable but required careful navigation in the group setting, especially when fathers were present.

Conclusions:

Participants identified unique benefits and barriers to addressing psychosocial topics in GWCC. Future research should explore the effects of GWCC on psychosocial disclosures and examine ways to enhance benefits while addressing the challenges identified.

Introduction

Latino children comprise nearly a quarter of the under-18 United States (US) population, and approximately half of Latino children have at least one immigrant parent.^1,2 Compared to non-immigrant families, immigrant families have higher rates of psychosocial stressors such as poverty,² food insecurity³, intimate partner violence (IPV)⁴ and postpartum depression (PPD).⁵ These stressors can adversely impact child health and development.^6,7 Moreover, psychosocial risks may go undetected for Latino children in immigrant families for a range of reasons including parent limited English proficiency (LEP)², parent preferences around communicating psychosocial information to providers,⁸ and the decreased likelihood of children in immigrant families having a medical home.^9,10

A redesign of pediatric well-child care has been proposed to more effectively identify and address family psychosocial issues.¹¹ Group Well Child Care (GWCC) is one form of care redesign in which the traditional 7–20 minute Individual Well Child Care (IWCC) visit¹² is replaced by a 90–120 minute visit in which a group of families with same-age infants attend the well-child visit together.¹³ The total visit time in GWCC is typically divided between brief (<10 minute) one-to-one (1:1) visits with the healthcare provider and a 45–60-minute multifamily group discussion with a provider and co-facilitator(s). One study identified a theoretical benefit of GWCC as simultaneously addressing maternal well-being and child health.¹⁴

While the American Academy of Pediatrics recommends considering GWCC to optimize well-child care in LEP populations,¹⁵ few studies have examined the experiences of immigrant Latino families with GWCC.^16,17 Moreover, no studies have specifically examined the feasibility and acceptability of addressing psychosocial topics within GWCC with this population. Integration of such topics into GWCC is critical to the identification and management of risk and resilience factors for families and children. However, it is unclear whether families find inclusion of psychosocial topics in group discussions acceptable, if providers feel comfortable facilitating sensitive discussions in this format, and whether the group dynamics ultimately support or discourage the effective inclusion of psychosocial topics. We therefore sought to explore the benefits and drawbacks of identifying, discussing, and managing psychosocial concerns in GWCC with immigrant Latino families through observation of GWCC sessions and interviews with mothers participating in GWCC and providers involved in GWCC facilitation.

Methods

Setting and Intervention:

The study took place at an urban, academic general pediatrics clinic serving predominantly Latino children with LEP immigrant parents. The institution began offering CenteringPregnancy group prenatal care¹⁸ in 2016. The pediatric clinic began offering CenteringParenting¹⁹ facilitated in Spanish in 2019, for patients ages 0–2. CenteringParenting is a model of GWCC developed by the Centering Healthcare Institute based on their CenteringPregnancy group prenatal care model. It includes developmental and postpartum screening and an individual (1:1) physical exam/health assessment followed by a facilitated, interactive multifamily group discussion focused on maternal and child health. In Centering models, all activities typically occur in the same room, with health assessments conducted in a semi-private space. Care processes of GWCC in the clinic (including developmental and psychosocial screening processes) and study procedures are shown in Figure 1. The study was approved by the Johns Hopkins University Institutional Review Board.

Figure 1: Study and Visit Procedures.

*For visit screening, clinic used the Spanish version of the Survey of Well-Being of Young Childhood (SWYC; © Tufts Medical Center 2010; Available at https://www.tuftschildrenshospital.org/the-survey-of-wellbeing-of-young-children/overview). It includes questions about developmental and behavioral milestones, maternal mood, and family context.

Study Design:

The research was designed as a case study of GWCC at the clinic.²⁰ We combined interviews with parents and providers, observations of the 1, 2, 4 and 6-month group visits, and surveys to gain an understanding of how psychosocial topics were identified and addressed.

Research Team:

The data collection team included: (1) RP-faculty at the institution affiliated with the clinic, non-Latina, proficient Spanish-speaker and (2) JA- Research staff, identifying as Latina, a native Spanish speaker. The data analysis team also included (1) JS – a graduate student, non-Latina, proficient Spanish-speaker trained in qualitative methods (2) ES – faculty and non-Latina English-speaking provider at the clinic, trained in CenteringParenting but not yet delivering GWCC.

Participants:

Participants included mothers and healthcare providers. Eligible mothers were aged ≥ 18, identified Spanish as their preferred healthcare language and elected GWCC for their infant’s care. Mothers (N=42 within seven separate GWCC cohorts) consented to observation of the group discussion portion of visits, review of their infant’s medical record and completing surveys and semi-structured interviews. Although several fathers participated in visits, mothers were considered the primary participants. All providers involved in GWCC at the site consented to being observed and interviewed, including 5 pediatricians, 2 social workers, a medical assistant, and a group visit coordinator. All providers were female. Participants received $15 for completing surveys and $30 for completing interviews.

Data Collection:

GWCC visits were observed by RP and JA for 7 different cohorts over an 11-month period. If either RP or JA could not observe, the group discussion was audio recorded by the attending research team member so that the other could listen to the recording later. The 1:1 portions of visits were not observed for reasons of confidentiality; however, in interviews participants were asked to reflect on the experience and content of the individual visit component.

Demographic surveys were completed by all mothers at baseline, satisfaction surveys, adapted from the Spanish version of the National Survey of Early Childhood Health,²¹⁾ were completed at 6-months. Individual, semi-structured interviews were conducted after participants had attended or delivered at least 6 months of group visits. We conducted 17 parent interviews, choosing at least 2 mothers per cohort. We purposefully selected mothers for sociodemographic diversity (e.g., level of education, number of children), PPD screening scores, and level of engagement in group discussions. We purposefully interviewed one mother who dropped out of GWCC due to preference for IWCC. Parent interviews covered topics including satisfaction with GWCC, feelings about discussing psychosocial topics in group, and the perceived quality of their relationship with their provider. All parent interviews were conducted in Spanish by JA. Spanish and English language transcripts were created from audio-recordings by an independent professional translator/ transcriptionist. Interviews with providers focused on the experience of delivering GWCC, benefits and drawbacks of GWCC, and discussion of psychosocial topics in group. Interview guides were refined iteratively over the course of the research based on regular discussions about observations and interviews.

Data Analysis:

Preliminary codebooks were created by RP and JA based on interview guide topics. Initial transcripts were reviewed independently by all members of the study team (Spanish-speaking members of the study team reviewed both Spanish and English-language transcripts); team discussions were used to iteratively refine the codebook. Codes were subsequently applied to the data, re-discussed and refined. Separate codebooks were created for parent and provider data. Observations and observation memos were used to inform the analytic process.

After initial open coding by the team, we used Donabedian’s framework²² to guide analysis, examining how the structure of group visits (e.g., time allotted to the visit and to different portions of the visit) may have impacted care processes and outcomes. We performed horizontal data analysis using the codebook as a matrix/framework hybrid. As has been done in previous studies,²⁴ we developed matrices in Microsoft Excel²³ to summarize each code, looking for subthemes and connections between themes and for patterns within and across types of data. The process was similar to Framework Analysis,²⁴ but coding and charting data into the framework were completed simultaneously. We reviewed and refined the framework analysis matrix through an iterative, collaborative process, meeting weekly to discuss codes, emerging themes, and any differences in interpreting or coding the data. Final themes were determined through group discussion.

Results

Participant characteristics for all mothers (N=42) and interview participants (N=17) separately are shown in Table 1. Four mothers dropped out of GWCC, one due to preference for IWCC, two because of conflict with their work schedules, and one who moved out of state. Participating pediatricians (N=5) had been in practice for an average of 7.8 years (range 1–15), reported variable degrees of experience with group facilitation prior to delivering GWCC and 2/5 identified as Latina. Both Social Workers identified as Latina, had >15 years in practice and experience with group facilitation prior to co-delivering GWCC. Both the Medical Assistant and Centering Coordinator identified as Latina and reported limited prior group experience.

Table 1 –

Parent Participant Characteristics

	Interviewed Parents	Overall parents in group
N	17	42
Age (mean, range)	29 (20–40)	29(19–40)
Number of children (mean, range)	2.2 (1–4)	3.1(1–4)
Live with partner	15(88%)	33(79%)
Country of origin
Mexico	0	1(2%)
Honduras	5(29%)	16(39%)
Guatemala	4(23%)	7(17%)
El Salvador	6(35%)	14(34%)
Ecuador	2(12%)	3(7%)
Years in the US (mean, range)	5.2 (0–19)	5.2(0–20)
Level of education
<6th grade	4(24%)	9 (21%)
6–8th grade	5(29%)	12(28%)
Some high school	3(18%)	12(29%)
High school graduate	2(12%)	5(12%)
Some college	3(18%)	4(9%)
Prior experience in CenteringPregnancy (group prenatal care)	12 (70%)	27(64%)
Prior experience with GWCC	0(0%)	0(0%)
2-mo Postpartum Depression screening results
EDPSa	4.9 (1–18; N=15)	4.7 (0–18; N=28)
PHQ9b	5 (3–7; N=2)	3.6 (0–19; N=11)
Satisfaction Survey: Your 1:1 time with provider lasted..	N=16	N=38
Too much time	0	0
Right Amount of Time	14(88%)	34(89.5%)
Too Little time	1(12%)	2(5.3%)
Not Sure	0	2(5.3%)
Dropped out of group (#, %)	1 (6%)	4(9.5%)

^a.EPDS= Edinburgh Perinatal/Postnatal Depression Scale. Reference: Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 1987.150:782–786.

Scoring: ≤8 Depression not likely; 9–11- Depression possible; 12–13- Fairly high possibility of depression; ≥14 Probable depression

^b.PHQ9 = Patient Health Questionnaire-9. Reference: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001. 16(9): 606–13

Scoring: ≤4= Minimal depression; 5–9= Mild depression; 10–14 Moderate depression; 15–19: Moderately severe depression; 20–27: Severe Depression)

Analysis of the interview data revealed two overarching themes, time and presence of peers, and several subthemes. For each subtheme, we explored perceived benefits and challenges of GWCC. Illustrative quotes are presented in Tables 2a (parent) and 2b (provider).

Table 2a –

Quotes from Parents

Theme	Subtheme	Benefits	Challenges
Time	Total Visit Time	Quote 1 “That is an extra benefit also because when one goes to the meetings, individual appointments, then its only based on the child, and they never ask how you’re feeling…So they do take a little time to ask us about how we’re feeling, what has affected us, if we’re feeling ok, if we have any problems. So that helps us as well...I mean, the group visit that I have now with this doctor, the doctor also focused on me a little, on how I am… what I can do to not feel so frustrated, so stressed with the, the nerve of these kids, so then that helps too”	Quote 2 “Well, sometimes it would be better if it were a little shorter... I think for me, for me it’s a little more difficult because I’m a single mother.”
	Duration of 1:1 Time with Providers	Quote 3 “It even includes the moments when we also have the individual because there are some doubts, and like the personal topics. So this is a very good moment as well, because maybe you have some, questions that, that are about personal topics…I think that it’s not like she says to one, I have mamas for these ten minutes, so, even though I understand it, I know that she would give me the time that I need. Even if it were ten minutes, I feel that more personal questions, there’s a lot of information here in that time”	Quote 4 “There are times that yes, things go very, very quickly...let’s say the doctor has time for so many people because then we have to start the group and so I feel like not calm being there. But that’s not because the doctor transmits it to me, rather it’s my own feeling that we have to finish so that another woman can come in, another mother, and we can start the group.”
Presence of Others	Social Interaction	Quote 5 “I feel good because sometimes we believe that we’re alone there, that nobody’s going to be listening, that nobody understands what we’re going through. And when we’re in that group, we start to learn and then you look at the faces and then sometimes she gives advice. So, she realizes that this is, well, if it’s something more but she sometimes needs help as well” Quote 6 “listening to the opinions of the other mamas and like one’s opinion, so it helps you a lot…sometimes you feel less stressed because we laugh there, and hearing things, the opinions, listening to the different opinions of each one. We laugh, and then that moves you, that’s it.”	Quote 7 “maybe one sometimes they have a problem or something but don’t want the whole group...to let them know everything that’s happening to them...it can be easier to say it to one person rather than a bunch of people, so then everyone knows...it’s not the same talking with anyone else about...because you say that well the people that you call more, like they say, this is one more educated, no the other one is the same as me, who knows me, who I tell something about my life, telling the other, what’s going on, what’s happening.”
	Sensitive Topics	Quote 8 “…it has helped me a lot, well not being afraid to say more personal things, like about having problems with a partner. Well to say that there is help, that it’s something that helps one that well, is not always able to be, to be good if they’re feeling this way, because there are always people that can help later…So no, I wouldn’t have any problem. I would even like to know so that if, one never knows what’s going to happen. If you knew what to do, then it would be something very good to talk about.”	Quote 9 “the thing was also it wouldn’t have been tense, the problem was that one of their husbands was there, so I think that’s why everyone like didn’t want to give their opinion, because there was a man there so…But a gentleman was there and well, uh, however you may be with your husband, talking about those things with women like yes, like it’s not very comfortable.”

Table 2b-.

Quotes from Providers

Theme	Subtheme	Benefits	Challenges
Time	Total Visit Time	Quote 10 “I’ve enjoyed it, it feels different…and I feel like I’ve gotten to know the moms a little bit better… I feel like I’m able to connect with the families in a more meaningful way due to the duration of the time that I get to spend with them.” (Pediatrician) Quote 11 And then it came up this sort of longstanding perception on the part of clinicians and social workers that this was not a familiar topic for women. I mean they might certainly have been something they observed, but that the vocabulary for it or how we ask about it as clinicians doesn’t really resonate with people…that there’s a false negative…ether ‘cause the way we say it doesn’t make sense, or it’s so socially undesirable or who knows what. So then with the social worker we decided that if we were gonna try a different form of screening, the value of the screening would go up if people had any idea what we were talking about…So, and that’s how we landed on really spending some time on that topic at the one-month visit. (Pediatrician)	Quote 12 “I think, I think there’s parents who don’t like the time because sometimes …they have to work and it’s hard for them to ask for a day off because like the Centering group is like half of the day, it’s not just like (an) individual, visit…like thirty minutes or one hour. But Centering is kind of like half the day” (Medical Assistant)
	Duration of 1:1 Time with Providers	Quote 13 “Yeah, I mean I still get to examine the kid and, you know, and in some ways, they’re not waiting as long as they would with the standard visit.” (Pediatrician) Quote 14 “…we came up with the idea if we, if we already pinpoint certain individuals that just need a little extra time, which for my group that was certainly the case, it was just a matter of like I’ll see them at the end” (Pediatrician)	Quote 15 “individually, when we have an individual visit they spend a lot of the early visits talking about who lives in your household, do you plan to go back to work, are you planning to stay home for a while. And… who do you turn to for support…and then after I’ve heard all that then I ask if you’re living with a partner is it a supportive partner, has he ever been violent towards you, you know, so that’s kind of like a nice gradual progression” (Pediatrician) Quote 16 “Sometimes I like collect the concerns and then we’ll deal with it in group. Or I just hope that they don’t feel like they’re being brushed off…” (Pediatrician)
Presence of Others	Social Interaction	Quote 17 “…it’s great for the moms to share… ‘cause they have a lot more common experiences, like I can tell them about me going on a website to find certified childcare providers that cost as much as college, and none of that information is gonna be relevant to what’s accessible to them. But they amongst themselves talked about…here’s why older women might be good ‘cause they’re sort of calmer…people had their different experiences and different suggestions about how they navigated it…they’re, living in a similar context, so it’s much more transferrable to the kind of information that would be helpful.” (Pediatrician)	Quote 18 “...it’ll be like partner dynamics, and we get three examples of how the husband is like awesome and then it’s like alright. And I know this person does not have a partner at all. And you know, but I don’t, I’m not gonna put them on the spot at the same time…I don’t know that this discussion was like helpful in providing emotional support or encouragement to someone who’s a, in a very different set of shoes.” (Pediatrician)
	Sensitive Topics	Quote 19 “…someone shared that they actually, I think they might have been like suicidal or psychotic as their postpartum depression manifestation. So, in a first visit this person shares that…and I was very grateful to her and publicly expressed like thank you for sharing that because people don’t talk about it much and it does happen. And I think that it made the experience more identifiable to the other women in the group…this isn’t just me presenting some extreme of it…I try to give an example of it really can affect every, anyone. It’s no evaluation of your strength or value, which I sometimes worry if that’s what people think. And I’m not sure but I just think there was so much more power in a personal testimony to something.” (Pediatrician)	Quote 20 “we need to be mindful that…these participants not necessarily want to discuss and if they don’t want to discuss their personal things, we need to put it out there that it’s very common, that this happens all the time to people that we know, and these are…this is where to talk, and to go in more information if they don’t share. And if they share, we need to be very tactful on how to transform that into information for everybody, and not into okay, I am disclosing, no?...Something that is too big to handle in the group…because this is one topic, among many topics that we need to address in the session…So there is not much time and you don’t want to say oh thank you for sharing, what’s next.” (Social Worker)

Theme 1 - Time

Total visit time

Mothers and providers described numerous benefits of the greater total visit time. Providers described that greater time facilitated consistent PPD and social needs screening completion among low-literacy mothers, likely due to opportunity to administer tools verbally. Time also facilitated more in-depth education and discussion about PPD, which was seen as an unfamiliar topic to many women (Quote 11). Most mothers described discussions about maternal well-being as valued and unique to GWCC (Quote 1). One provider also described GWCC as affording the opportunity to link more “biomedical” topics, such as vaccines, to psychosocial issues (e.g., parenting): “The fact that we had time to talk about prepping for vaccine administration and not to threaten your kids with injections... I don’t get to that at a 1- month visit any other day”. We observed these types of linkages (biomedical to psychosocial) occurring frequently. We also observed many group discussions about immigration-related topics (e.g., the public charge rule) impacting family decisions around relevant resources (e.g., food benefits); as well as more general discussions about the availability of supports to assist with families’ social needs.

Mothers and providers acknowledged the time commitment required to participate in GWCC. The need to block out several hours limited some families’ participation (Quotes 2 & 12). One provider described the challenges faced by a mother whose partner was deported during her pregnancy: “she’s now a single mother of four kids, and she just can’t take the time...But time with other adults with whom she shares a language, and support for her parenting now that she’s parenting on her own, those could potentially be very meaningful.”

Duration of 1:1 portion

Providers described several concerns about the duration of the 1:1 portion of visits, while most mothers generally did not express concerns. Several pediatricians noted that individual time with parents was critical to establish rapport and to gradually build towards discussing psychosocial topics and/or addressing needs identified by screening, asking sensitive questions, and obtaining a social history. They noted that these processes were truncated by the shorter 1:1 sessions in GWCC (Quote 15). Providers described strategies for providing extra time to families whom they perceived as needing more individual attention, either by scheduling the 1:1 portion of the visit after the group discussion or scheduling additional follow-up appointments (Quote 14). One provider noted “I think there have been some parents that have been a little more anxious, or just have needed or requested … more … one on one.… there’s one in particular, I think we’ve been able to still embed her in the group discussion. And for her wellbeing, my own clinical assessment is this individual is in a better, safer place as part of this group.”

Several providers perceived a tradeoff between establishing rapport in the 1:1 portion of the visit and the opportunity for enhancing social support and connection among families in the group discussion. Conversely, some providers described a more personal connection with GWCC patients as compared with IWCC patients (Quote 10). Mothers tended to share this perspective, with many mentioning that they enjoyed hearing from the providers about their own experiences with motherhood in group discussions. In satisfaction surveys, 90% of mothers (34/38) reported feeling the 1:1 time with the provider was sufficient.

Theme 2: Presence of peers

Social Component

Many mothers described GWCC as providing an opportunity to relieve stress through gathering with other parents (Quote 5). Mothers who had recently arrived in the US described being socially isolated and appreciated making social connections; one recently-arrived mother stated “I don’t have friends, right? But here is like having friends”. First-time mothers reported that listening to mothers with more experience reduced their worries or fears about their infants. Those with more experience described enjoying sharing their expertise with others and discussing new topics such as self-care alongside first-time mothers.

The practical nature and educational value of group discussions about psychosocial topics was seen as an advantage of GWCC. While emphasizing the importance of the provider for delivering health and safety education, providers also appreciated facilitating group discussions among women themselves, particularly in the context of parenting, childcare, and family planning as a recently arrived immigrant, for which many women had common lived experiences. (Quote 17) In addition to shared experiences, mothers also appreciated learning from each other about cultural differences related to being from different countries of origin.

The perceived drawbacks of the social component of GWCC stemmed largely from mothers’ uncertainty about whether they would be judged by (or could trust) other group members (Quote 7). Additionally, while many mothers perceived social benefits to participating in GWCC, most reported not interacting with other parents outside of the group. One mother expressed disappointment about the lack of socializing outside of GWCC, “that’s what the group is for, to unite us a little so we can get together because we’re mothers, we’re friends, we’re Latinas, and why not be united outside of the group as well?”. One provider hypothesized that GWCC’s less frequent appointment schedule (relative to other types of group meetings such as support groups) made it difficult to develop trust. Conversely, several participants highlighted the development of trust over time.

Sensitive topics

Although concerns were raised about privacy and trust within the group, group discussions about sensitive topics (e.g., PPD, partner relationships, social needs) were generally well-received. Providers and mothers described group discussions about depression and partner relationships as normalizing sensitive topics (Quote 19). With respect to PPD, one mother stated, “when I saw that it was something normal, it’s something that was talked about in the group...that’s what was happening to me for a while because sometimes one believes that one is alone, but no, there are a lot of us”.

Some providers were concerned about sensitive disclosures in the group setting, both because of the need to address a range of topics in the group discussions and because of the risks should information be shared (Quote 20). Some felt that the best use of group time might be to put sensitive topics “on the table,” rather than encourage disclosures to the group. While some mothers stated they would feel comfortable sharing with the group, many expressed a preference to discuss personal information or potentially stigmatizing topics individually (Quote 7). We observed providers regularly reminding parents of their availability for individual discussions if preferred. While orally-administered screeners were conducted individually and discreetly in a common area prior to the group discussion, providers expressed concerns that the area may be too exposed for more sensitive questions and may also expose a participant’s limited literacy.

In four of seven GWCC cohorts, fathers were present during at least 1 observed session. Mothers and providers acknowledged that the nature of group discussions changed when fathers were present, particularly around topics such as IPV. One provider noted, “I really like the dads there but sometimes I feel like I can’t bring up certain things…I’m also conscious of some of my families who don’t have partners for whatever reasons, whether choice or not…to raise their child alone”. Mothers and providers thought some parents would not want to give their opinions about certain topics in the presence of males (Quote 9). However, mothers whose partners attended reported valuing the opportunity to learn alongside their partners; one mother noted that her partner’s attendance at GWCC facilitated their decision about birth control. Another mother theorized that having both parents attend could facilitate shared implementation of parenting strategies.

Discussion

In examining how psychosocial topics were addressed in GWCC with immigrant Latino families, we focused on two aspects of GWCC that differentiate it from IWCC: time and the presence of peers. Consistent with prior studies with other populations,²⁵ we found that that the longer total visit time facilitated well-received discussion and education around topics such as PPD, parenting and maternal well-being. While longer total visit time reduced barriers to psychosocial screening administration for parents with limited literacy, providers expressed concerns about the impact of shortened 1:1 time on their ability to develop rapport, follow up positive screens or adequately discuss sensitive topics individually. Mothers valued the opportunity to make social connections and to learn from the lived experiences – both shared and divergent – of other mothers. While maternal testimony about sensitive topics such as postpartum depression could be educational and powerful, some mothers preferred to discuss these issues in private; and providers expressed concerns about navigating disclosures in the group. Having fathers present in the group created additional challenges when discussing topics such as IPV, but also provided educational benefits for families.

The focus on maternal well-being in GWCC has been previously reported with other populations.²⁵ However, there may be unique benefits to these discussions with immigrant Latino families given prior reports of limited mental health literacy,²⁶ stigma around topics such as maternal depression²⁷ and the increased mental health risks to immigrant families in the current sociopolitical context.²⁸ Prior research on GWCC with immigrant Latino parents has described benefits of increasing parent support and self-efficacy and facilitating discussions about common stresses around immigration.¹⁷ Moreover, time for practical discussions around immigration policy and child benefits are critical given the known “chilling effect” that announcements of policy changes have had on utilization of public benefits for children in immigrant families.²⁹

The balance of increased time for psychosocial screening with decreased time for individual psychosocial discussions warrants further exploration. While the importance of PPD screening is widely recognized,¹⁰ there is little in the literature on mental health screening with LEP populations in pediatric primary care.³⁰ GWCC may introduce new challenges around oral screening in public spaces and thus merits development of specific, feasible and acceptable procedures that address those privacy challenges. While providers expressed concerns about rapport-building during the shorter 1:1 time, consistent with prior GWCC studies,^{25, 31} these concerns were not generally echoed by mothers. Providers and mothers described making personal connections via the group discussions, consistent with prior studies describing less hierarchical communication in GWCC as compared to IWCC.¹⁷ The fact that all providers were Spanish-proficient may also have contributed to parents’ perception of rapport despite the shorter individual meetings with providers.³² Nonetheless, it is important to continue to examine parent-provider rapport in GWCC given the role of rapport in mothers’ decisions to disclose psychosocial information to providers.³³ The role of group discussions in parent decisions to disclose psychosocial information also warrants further study. Similar to studies of GWCC with other populations,²⁵ several participants expressed a preference to discuss personal information individually. One potential use of group discussions may therefore be to lay the foundation for families to continue conversations about psychosocial topics and disclose more sensitive psychosocial issues in subsequent individual visits or in other settings.

While mothers reported benefit around discussions about partner relationships and providers wanted to promote fathers’ involvement in GWCC, both mothers and providers described discomfort discussing topics such as IPV with fathers present. Given the public health importance of identifying and addressing IPV in immigrant families,³⁴ further exploration around effective involvement of fathers in GWCC is indicated. One way to address this tension may be to designate portions of certain visits as single gender. In navigating such an arrangement, it is important to consider that fathers may feel deterred by perceptions that they are treated differently than mothers.³⁵

This study has several limitations. It occurred at a single site, and some issues raised may have been unique to this site and its characteristics (e.g., group room size, clinic resources, availability of bilingual staff), limiting the generalizability and/or scalability of our findings. Since all providers were female and all sessions occurred with Spanish-proficient clinicians, we could not explore effects of provider gender or delivery of content through interpreters. Parents in this study had actively chosen GWCC, and more than half had participated in group prenatal visits, thus there may be selection bias in that study participants may have a more positive opinion of group care than parents choosing IWCC. Finally, the longer time commitment may make GWCC less accessible to parents with inflexible work schedules, suggesting a need to identify and minimize inefficiencies in the model. Notably, during COVID-19 pandemic restrictions, several mothers elected to participate in virtual group discussions even while at work, suggesting the potential for the virtual format to allow more inclusion (while introducing new challenges around telehealth access and confidentiality).

Well-child care provides an essential opportunity to identify risk and enhance resilience for children in immigrant families.² GWCC has the potential to provide structure and space to address immigration-related stressors, unmet maternal health needs, and engage families in optimizing child and family health. In addition to examining outcomes such as parent health literacy and psychosocial disclosures, and comparing these outcomes to those in IWCC, future studies of GWCC should explore strategies to both enhance and maximize potential benefits, while effectively navigating drawbacks.

What’s New.

This multimethod study describes benefits and challenges of implementing of group well-child care and provides insights into how this model may be modified to improve identification of psychosocial risk and enhance resilience for Latino children in immigrant families.