Parents’ Preferences for Behavioral Services in Primary Care during the COVID-19 Pandemic

Abstract

Objective:

Pediatric primary care is an ideal setting to provide behavioral health services to young children and their families during the COVID-19 pandemic. However, it is unclear how the pandemic altered parents’ priorities and preferences to obtain behavioral services in this setting.

Method:

Between July 2020 and January 2021, 301 parents of young children in five pediatric sites across the United States completed survey measures on their preferences for behavioral topics and service delivery methods in primary care. The current sample was compared to a previous sample of parents (n = 396) who completed the same measures in 2018.

Results:

Child self-calming was the only behavioral topic that was rated as significantly more important in the pandemic cohort in comparison to the pre-pandemic cohort. The pandemic cohort also reported significantly more interest in using certain media resources (e.g., mobile apps, videos) as a delivery method and less interest in group classes/seminars. After controlling for demographic differences between the samples, there was an increased preference for multimedia resources overall in the pandemic cohort, as well as a decreased preference for usual care.

Conclusion:

Parents generally endorse similar priorities for behavioral topics in primary care during the pandemic as they did prior to the pandemic. However, there is a clear preference for more remote and media-based services during the pandemic. Pediatric practices may consider augmenting behavioral health services with multimedia resources during and after the COVID-19 pandemic in order to meet parents’ needs.

The COVID-19 pandemic has caused significant challenges for children and families, and the need for behavioral health support is high.¹ Pediatric primary care is an ideal setting to provide behavioral interventions to children and families.^2–3 However, engagement with integrated behavioral health (IBH) services may be impacted by shifting needs and preferences of families during the COVID-19 crisis. Further, changes in primary care delivery in reaction to COVID-19 (e.g., declining wellness visits and screenings; and increased telehealth services) have disrupted the modalities in which IBH was traditionally delivered.^4–5

A previous study found that parents of young children most often prefer to address child behavior within the context of routine well-visits.⁶ A majority of parents also endorsed interest in separate behaviorally-focused visits, either with primary care clinicians (PCCs) or behavioral health consultants (BHCs). Parents of children with clinically significant behavioral issues were more likely to endorse interest in distance-based and digital interventions (e.g., telephone calls, mobile apps) than those who did not report significant problems. Given potential for increased parental stress and child behavior problems in the context of the pandemic,^1,7 and changes in available IBH delivery modalities, it is important to determine how parents’ attitudes towards IBH services may have shifted.

In this study, we sought to assess parents’ preferences for behavioral health interventions in primary care during the COVID-19 pandemic and to compare these preferences to a pre-pandemic sample. Specific research questions were as follows: 1) What child behavioral topics are most frequently endorsed by parents as important to address during the COVID-19 pandemic? 2) What IBH delivery modalities and intervention approaches are most frequently endorsed by parents as interesting or useful during the COVID-19 pandemic? 3) Are there significant differences between the pandemic and pre-pandemic sample on parents’ preferences for behavioral health topics and IBH delivery modalities and interventions? Given the context of the pandemic, we hypothesized that there would be an increased importance of childhood behavioral topics, a decreased interest in in-person delivery modalities, and an increased interest in distance-based modalities.

METHOD

This study was a collaboration of members of the Pediatric Integrated Primary Care Research Consortium, a co-operative of pediatric IBH researchers and clinicians. Methods were approved by human subjects institutional review boards at each of the participating institutions.

We recruited English- and Spanish-speaking parents of children between the ages of 18 months and 5 years 11 months through five primary care practices: one academic medical center-based pediatrics clinic in Oregon, one Federally Qualified Health Center (FQHC) family medicine practice in Kansas, and three hospital-affiliated community clinics in Ohio. Parents were recruited between July 2020 and January 2021. Recruitment procedures varied across clinics, and were largely driven by pandemic-related institutional restrictions on research procedures. At the Ohio clinics, we recruited the parents of consecutive patients who attended well-child visits (in-person or virtually) via patient portal messages and in-clinic recruitment; at the Oregon clinic we used patient portal messages only. At the FQHC, recruitment text messages were sent to the parents of all children in the target age range with an available phone number using an existing patient communication system. Parents who were interested in participating were provided a link to an online REDCap eligibility screening and survey.⁸

In total, we attempted to contact the parents of 1,938 children, though it is likely a significant portion of the patient portal and text messages were never received. Of the 900 patient portal messages delivered to parents at the Oregon clinic, 30% were never opened. Receipt of text messages (N = 549) is unknown. Further, recruitment through child medical records likely resulted in some parents of siblings receiving multiple invitations, despite eligibility to participate only once. Ultimately, 423 entries were created in the REDCap system, of which 33 were deemed ineligible for participation. Of the 390 eligible parents, 309 (79%) enrolled in the study and completed at least one measure.

Pre-Pandemic Reference Sample

In order to draw comparisons with a pre-pandemic sample, data collected in 2018 from a previously published study were used as a historical reference.⁶ The pre-pandemic study utilized the same eligibility criteria and online survey method as the pandemic study, but differed with regards to recruitment settings and methods. In the previous study, participants were recruited from five practices in the Pacific Northwest, only one of which was included in the current study. It is possible some participants from this clinic participated in both studies. The change in recruitment settings was driven by our desire to capture a more racially/ethnically, geographically, and socioeconomically diverse sample. All recruitment for the pre-pandemic study was conducted during clinic visits and 91% of eligible parents participated in the study.

Measures

Demographics.

Participants completed a demographics questionnaire about race/ethnicity, family composition, household income, and parent education levels. Parents were asked to report on their oldest eligible child in the study age-range to encourage a wider distribution of child ages.

Preferences for Primary Care Behavioral Services.

Participants completed a version of the Behavioral Information Preferences Scale (BIPS), a measure of parents’ preferences for the topics and delivery modality of behavioral guidance in primary care. The BIPS was initially developed for the pre-pandemic reference study⁶ and subsequently psychometrically evaluated using the same sample.⁹ The BIPS consists of 39 five-point Likert-type items. Two BIPS subscales measure interest in behavioral topics: Emotions and Conduct (BIPS-EC; α = .96 in the current sample), including topics related to internalizing (e.g., difficult emotions) and externalizing concerns (e.g., aggression); and Healthy Habits (BIPS-HH; α = .83), including topics related to daily habits and developmental skills (e.g., toilet training). Three subscales assess interest in potential service delivery modality domains: Usual Care (BIPS-UC; single item), referring to behavioral care from PCCs during usual office visits; Auxiliary Care (BIPS-AC; α = .86), referring to synchronous interactions with a PCC (beyond usual care) or BHC; and Multimedia Resources (BIPS-AC; α = .88), referring to text or technology-based (e.g., “Mobile apps for smartphones or tablets”) interventions. The BIPS also includes an Intervention Approach section that provides supplementary information about parent interest in specific intervention strategies (e.g., stress management), but does not yield a summary score.

For the purposes of the pandemic study, we modified the BIPS in two ways by adding 1) the phrase, “…during the COVID-19 pandemic or similar events” to the instructions for each section and 2) supplementary items to capture topics (e.g., discussing COVID-19 with children) and delivery modes (i.e., virtual care options) relevant to the pandemic. Supplementary items did not contribute to summary scores.

Analyses

We used descriptive statistics to characterize the sample. Depending on the nature of the data, we conducted t-tests, chi-square tests, and Mann-Whitney U tests to contrast the current sample with the pre-pandemic reference sample.⁶ To summarize responses to individual BIPS items, we calculated the percentage of participants that endorsed a 4 or 5 (e.g., “Important” or “Very Important”). We conducted Mann-Whitney U tests to test whether responses on individual BIPS items were significantly different between samples. We conducted Wilcoxon Signed Rank tests to examine within-group differences between the supplementary virtual care BIPS items (e.g., “Attending virtual (audio and visual) group classes or seminars with other parents”) with in-person equivalents (e.g., “Attending in-person group classes or seminars with other parents”). We also conducted ANCOVA analyses comparing the pandemic sample’s BIPS subscale scores to the pre-pandemic sample. We included ethnic/racial identity, household income, and parent education as covariates to control for demographic differences between the samples. Alpha was set at ≤ .05. We used Holm’s Sequential Bonferroni Procedure to correct for multiple comparisons.¹⁰

RESULTS

Table 1 displays the participants’ characteristics contrasted with the pre-pandemic reference sample. Most parents were female and 43% identified as a racial minority. Compared to the pre-pandemic sample, the current sample of parents was significantly more female, less likely to identify as White, and more likely to identify as Black or African American.

Table 1.

Participant and Comparison Sample Characteristics

	Pandemic (N = 301)		Pre-Pandemic (N = 396)
Characteristic	Parents	Children	Parents	Children
Age, years, M (SD)	33.58 (7.10)	3.40 (1.2)	33.33 (6.27)	3.52 (1.32)
Female sex, %	90	49	85*	46
Ethnicity, %
Hispanic/Latino	12	16	15	17
Race, %
White, non-Hispanic/Latino	56	55	67**	66**
Asian	14	15	11	11
Black/African American	15	20	2***	4***
American Indian/Alaska Native	2	3	3	3
Native Hawaiian/Pacific Islander	1	2	2	2
Other/Unknown	10	6	14	14
Marital Status, %
Married	67		76
Divorced or separated	9		5
Never married	24		16
Other	0		3
Number of children, M (SD)	2.02 (1.17)		2.06 (1.07)
Parenting Situation, %
Single parenting	16		11
Couple parenting, same household	78		84
Co-parenting, separate households	6		5
Education, %
High school diploma or less	17		13
Vocational school/some college	19		20
College degree	34		41
Graduate/professional degree	30		26
Annual Household Income, %
$25,000 or less	22		12
$25,001–$49,999	20		25
$50,000–$79,999	16		27
$80,000–$119,999	11		15
$120,000–$149,999	10		9
$150,000 or more	22		13

Note: Parents were asked to report on their oldest child in the target age range;

^*Difference between samples is significant at p ≤ .05;

^**p ≤ .01;

^***p ≤ .001.

Table 2 shows the percentage of parents who endorsed each BIPS item in the pre-pandemic and pandemic samples. Helping children learn to cope with difficult emotions, child self-calming, and tantrums were the most commonly endorsed behavior topics in the pandemic sample. Parents in the pandemic sample rated child self-calming significantly more important than the pre-pandemic sample. No other behavioral topics differed significantly.

Table 2.

Parent Endorsement of Child Behavior Topics, Delivery Methods, and Intervention Approaches for Primary Care Behavioral Guidance Before and During Pandemic

	Percentage of Parents Endorsing
BIPS Items	Pandemic Cohort	Pre-Pandemic		p
Behavior Topics Section1
Emotions and Conduct
Coping with difficult emotions	80	74		.03
Self-calming	79	72		.001*
Tantrums	76	77		.74
Aggression	70	74		.08
Listening to instructions	69	67		.53
Sharing	68	66		.50
Destruction	67	70		.22
Misbehavior in public	64	67		.21
Being honest	64	60		.47
Following rules	62	61		.52
Transition between activities calmly	55	50		.02
Inappropriate speech	51	52		.90
Healthy Habits
Sleep	69	68		.55
Picky eating	67	73		.45
Toileting	66	64		.97
Attentiveness	60	55		.08
Limiting screens and toys	59	63		.96
Bad habits	42	51		.03
Delivery Methods Section
Usual Care
PCC – routine visita	71	81		.03
Auxiliary Care
Behavior specialist – routine visitb	63	61		.22
Behavior specialist – separate visit	50	48		.25
PCC – separate visitc	46	52		.13
Behavior specialist – phone	44	46		.88
Group class/seminard	25	35		.001*
Supplementary Items
PCC – routine visit virtuala	61	-		-
Behavior specialist – routine virtualb	59	-		-
PCC – separate visit virtualc	59	-		-
PCC – routine visit phone	43	-		-
Group class/seminar – virtuald	39	-		-
Media Resources subscale
Patient portal	65	47		<.001*
Mobile apps	63	48		<.001*
Books	59	47		.001*
Online programs	55	45		.01
Websites	53	49		.19
Videos	53	41		.003*
Podcasts	44	32		.001*
Paper handouts	41	45		.75
Social media	24	22		.71
Intervention Approach Section3
Typical/atypical behavior	84	89		.58
Positive parent-child relationship	76	83		.13
Stress management	71	80		.24
Consequences for misbehavior	71	69		.46
Set expectations for child behavior	66	75		.05
Reward/approval of good behavior	66	68		.70
Supplementary Items
Creating daily routines	59	-		-
Talking to your child about COVID-19	53	-		-

Note:

^{a, b, c, d}Denotes within-group pairs of in-person and virtual equivalents that are statistically different at p ≤ .001.

^*Significant between-groups differences using Holm’s Sequential Bonferroni Procedure; PCC=Primary care physician;

¹Endorsed as “Important” or “Very Important;”

²Endorsed as “Interested” or “Very Interested;”

³Endorsed as “Useful” or “Very Useful.”

With regard to delivery methods, talking to a PCC about behavior during routine care was the most frequently endorsed method, as it was in the pre-pandemic sample. The pandemic sample reported significantly more interest in receiving behavioral information via patient portal, mobile apps, books, videos, and podcasts compared to the pre-pandemic sample, whereas interest in in-person group classes/seminars was significantly reduced. A majority of parents endorsed interests in multiple virtual care options. Within group comparisons of the pandemic sample showed a greater preference for virtual than in-person care for separate PCC visits and for group classes/seminars. Conversely, parents preferred in-person care over virtual care for routine visits with their child’s PCC or a BHC.

The pandemic cohort scored significantly higher on the BIPS-MR subscale (M = 29.52, SD =8.2) in comparison the pre-pandemic cohort (M = 27.28, SD = 8.7), F = 8.71, p < .01, Partial η² =.01. Further, the pandemic cohort scored lower on the BIPS-UC subscale (M = 3.93, SD = 1.1) in comparison the pre-pandemic cohort (M = 4.11, SD = 1.0), F = 7.16, p = .01, Partial η² = .01. There were no significant differences on the other subscales. The full results of ANCOVA analyses comparing BIPS subscale scores in the pandemic and pre-pandemic cohorts can be found in Table 3.

Table 3.

Comparison of Pre-Pandemic and Pandemic Cohorts on BIPS Subscales

BIPS scale	Pre-pandemic cohort (M, SD)	Pandemic cohort (M, SD)	ANCOVA F	p	Partial η2
Conduct & Emotions	49.30 (12.8)	49.57 (13.0)	.26	.61	.00
Healthy Habits	18.71 (4.6)	18.24 (4.8)	3.82	.05	.01
Multimedia Resources	27.28 (8.7)	29.52 (8.2)	8.71	<.01*	.01
Auxiliary Care	16.11 (4.8)	15.78 (5.6)	1.91	.17	.00
Usual Care	4.11 (1.0)	3.93 (1.1)	7.16	.01*	.01

Note: BIPS = Behavioral Information Preferences Scale; covariates were parent race, ethnicity, education, and income;

^*p ≤ .05

DISCUSSION

This is the first study to examine parents’ attitudes toward primary care behavioral supports during the COVID-19 pandemic. As was true pre-pandemic,⁶ parents reported high interest in addressing child emotion regulation topics in primary care, with significantly increased interest in teaching children to calm themselves. This may reflect increased child irritability and agitation during the pandemic¹¹ and demand for child self-regulation as caregivers split their attention between childcare and working from home.⁷

Replicating and extending pre-pandemic findings, in-person well-child visits continued to be the most preferred modality of IBH services. However, for separate behavior-focused visits with PCCs, caregivers preferred virtual care to in-person. This may reflect a perception that in-person care is important for addressing physical health, whereas behavioral topics are more adequately managed via virtual care. Group classes were the least preferred mode of intervention for both in-person (25%) and virtual (39%) modalities, with significantly reduced interest in in-person classes compared to the pre-pandemic sample.

Parents’ increased interest in digital media resources including mobile apps, videos, podcasts, and intervention through patient portals, is a novel finding. Increased openness to digital media resources may reflect desires to practice social distancing or increased comfort with digital media resources gained from navigating work, school, and other family needs virtually during the pandemic. Whether this shift in preferences persists post-pandemic will be a matter of future study, but continued increased use of telehealth and other digital modalities is likely^12–13 and primary care teams are well-positioned to engage parents in high quality, trustworthy digital media resources.

This study should be interpreted within the context of its limitations. Participants completed an online survey, which may have biased results towards digital interventions; however, the methods were similar to the pre-pandemic study.⁶ It is also possible that the clinic-only recruitment method may have resulted in increased sampling bias, given pivots to telehealth services and overall reductions of in-person care during the recruitment period. Additionally, few fathers and non-parent primary caregivers participated, which may limit generalizability of results. Future studies should explore how demographic and clinical characteristics are related to parental preferences for IBH. For instance, we were unable to compare preferences for parents of children with or without significant developmental or behavioral issues, although previous research suggest there may be differences in preferences for delivery methods for parents of children with significant behavioral issues.⁶ Future research may also evaluate how attitudes for behavioral health delivery may change or persist as the pandemic continues. Finally, more research is needed to examine how parent-stated preferences are related to their actual engagement in available IBH resources, particularly for digital media resources.

Overall, our findings indicated a continued high need for IBH services amongst the parents of young children, and suggest an increased openness for engaging with virtual care and other digital resources. Responsiveness to shifting preferences for service delivery in the wake of the pandemic is an important aspect of family-centered care.