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ARTICLE |
a Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
b St Francis Hospital Medical Center, Hartford, Connecticut
c Department of Psychology, University of Connecticut, Storrs, Connecticut
d Connecticut Children's Medical Center, Hartford, Connecticut
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. Mothers with children between 3 and 12 years of age who identified themselves as African American, Jamaican, Haitian, or Puerto Rican were recruited from community sites. Audiotaped focus groups were conducted by trained moderators using an interview guide, to obtain the perspectives of the participants regarding the role of pediatric providers in the provision of parenting advice.
RESULTS. Ninety-one mothers participated in a total of 20 focus groups, with 4 to 6 discussions per ethnocultural group. The focus groups revealed that, in general, parents do not look to child health care providers for advice on raising their children. The identified themes emphasized the importance of the relationship between providers and families. A few parents had the type of relationship within which the pediatrician already functioned as a provider of parenting advice. Physicians were considered skilled in the maintenance of physical health. The parents expressed a desire to receive more anticipatory guidance on developmental and behavioral stages and milestones. Pediatricians also served specific administrative functions valued by parents.
CONCLUSIONS. Minority parents of preschool-aged and school-aged children do not view the primary care provider's role as including the provision of parenting advice. Expectations must be modified to enable health care professionals to function effectively in the role of advisor regarding parenting issues.
Key Words: parenting • anticipatory guidance • focus groups • minority groups • racial/ethnic groups
Professional guidelines encourage providers to offer parenting advice to parents.1–4 Furthermore, the Accreditation Council for Graduate Medical Education requires residency programs to train pediatric residents effectively in the provision of counseling and anticipatory guidance to families.5 These guidelines are supported by studies suggesting that parents are not receiving as much guidance as they desire regarding how to care for their child6 and that they look to their child's pediatric provider as a primary source of parenting advice.6–9 Most data are derived from nonminority populations.6,7
The current and projected pool of pediatric providers is not representative of the ethnocultural diversity seen within the patient population.10 Census Bureau estimates are that, by the year 2050, non-Hispanic white individuals will constitute 50.5% of the US population, with the remaining 49.5% divided as follows: Hispanic origin, 25.7%; black, 13.8%; Asian, 9.2%; Native American, 0.8%. These projections of increasing diversity highlight the importance of obtaining the perspectives of parents from various backgrounds, to meet their needs adequately. A recent study by Olson et al11 found that, in general, parents and pediatricians were satisfied with the amount of time available for health supervision visits but parents reported many needs remaining unmet; unmet needs were higher for black and Hispanic parents. A better cross-cultural understanding of parental attitudes, perceptions, and expectations regarding the doctor's role as advisor is clearly needed to inform the content and process of child health supervision services.
Although child health supervision services focus on parenting challenges throughout childhood and adolescence, generally studies have been conducted with parents of children between birth and 3 years of age. Limited information is available on the views of parents of older children. The goal of this study was to use focus groups to explore the views of minority parents of children >3 years of age regarding the role of the pediatric provider as a resource on parenting.
A growing body of literature describes the use of focus groups to elicit parents' perspectives.12–14 In general, this method is used to assess knowledge, attitudes, experiences, and expectations, to learn not only what people think but also how and why they think and feel as they do. Such insight into parents' perceptions provides an opportunity to derive meaningful implications for practice. In this study, focus groups were used to explore the perspectives of minority parents regarding the pediatric health care provider's role as parenting advisor.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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1 child between 3 and 12 years of age. Parents selected their preferred language for participation. The African American and Jamaican groups were conducted in English, as were one half of the Puerto Rican groups. The other half of the Puerto Ricans groups were conducted in Spanish, and the parents who self-identified as Haitian participated in groups conducted in Haitian Kréol/Kreyol. Institutional review board approval was obtained for this research study from St Francis Hospital and Medical Center and Connecticut Children's Medical Center (Hartford, CT). Institutional review board approval at those 2 hospitals also met the needs of the participating community organizations. Informed consent was obtained at the start of each focus group.
Data Collection
Standard focus group methods were used. Moderators of the same ethnocultural background as the participants were trained uniformly to facilitate the focus groups and used a standardized guide. Questions for the groups were developed in a multiphase iterative process that included a review of the literature on parenting and the role of the pediatric provider and input from pediatric providers and community members from the 4 ethnocultural groups (Table 1). The discussions focused on parenting and the role of the pediatric health care provider. The questions were sequenced so that the first third were introductory in nature, allowing the participants to become comfortable. The middle third were the key questions dealing most directly with the research study's primary focus (eg, Would you go to or call your child's doctor for advice about raising your child? If no, why not? If yes, what kinds of advice about raising your children would you go to their doctor for?). The last third of the questions allowed the participants to summarize what they thought were the key points. The groups were held either in the evening or on weekends, to accommodate the participants' schedules. Groups were held in locations within the community that were easily accessible to the participants. Refreshments, child care, and transportation were provided as needed. The discussions lasted 
1 hour and were audiotaped. At the conclusion of each focus group, the participants provided demographic data about themselves through the completion of a 20-question survey. The transcripts from the non-English groups (3 in Spanish and 5 in Haitian Kréol/Kreyol) were translated and verified through back-translation, to facilitate review of the transcripts by the research team.
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30 minutes and served as the beginning of the analytical process. One of the functions of the debriefing was to assess saturation. In the conventional understanding of the concept, saturation has been reached when no new ideas or themes are identified and the gain from conducting additional groups is minimal.15
Expert Collaboration and Theme Compilation
The audiotape from each focus group was transcribed immediately verbatim. Each transcript was verified by at least 1 person other than the individual who transcribed/translated it, to ensure completeness. The transcripts incorporated field notes collected during the focus groups by the moderator and principal investigator. These field notes included affective responses (eg, laughter) and nonverbal responses of the participants (eg, shaking head in agreement).
The principal investigator and 3 coinvestigators formed an analysis team. Three of the team members were pediatricians, and 1 was an anthropologist. Before the start of the transcript reviews, the 4 team members met several times and agreed to review each transcript independently, noting main ideas or themes.
All of the analysis team members brought their individual expertise to the text as they reviewed each transcript. This type of exploration of textual data for themes is consistent with the concept of content analysis described by Pope et al17 and Brown.18 In addition, the principal investigator reviewed the data at multiple points, including observing each of the 20 focus groups, participating in postgroup debriefing, listening to each audiotape, and reviewing the completed transcripts. This analytical approach of conducting multiple cycles of text review is referred to as immersion/crystallization.19
After the team members reviewed each transcript individually and derived a list of themes independently, they met and reached consensus on the emerging themes through a process not unlike the focus group process. After undertaking this process with the transcript from each of the 20 focus groups, the analysis team summarized and consolidated the findings from all of the groups. As review of the 20 transcripts continued, consensus was reached regarding the core themes, compared with the unique themes. These findings were then organized into overarching ideas (domains), themes, and subthemes (Fig 1). This means of organizing the identified ideas from a series of focus groups is an accepted practice.12,14,20 Atlas.ti,21 a software program designed to support qualitative data analysis, was used to assist in the data management process.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Domain I: Doctors Are Not Seen as a Primary Source of Advice on Raising Children
The primary finding across all 4 ethnocultural groups is that minority parents do not look to the pediatric health care provider for advice on raising their children.
I don't think we as parents think that the doctor helps us to raise our children as I think more... of the doctor helping us to keep our children healthy as we raise our children.
When I think of the term "raising the children," I'm thinking of their social skills, their personality, their well-roundedness as a human. But I don't think of asking their doctor about raising them.
I wouldn't call to ask how to raise one of my children. ... If there is something else other than that, like as in medicine or something, then fine. But as for raising the child, it is the household, it is our responsibility to raise the child.
These parents thought that the doctor played an important role in their and their children's lives. The doctor's role, as they describe it, is to help parents keep their children healthy. Raising their children, which they describe as instilling social skills, shaping their personality, and ensuring that they are well-rounded human beings, is seen as belonging more appropriately within the realm of the family.
Some parents simply never considered getting advice on raising their children from a pediatric health care provider.
Oh, please, I wouldn't even consider the doctor.
It never entered my mind to call the pediatrician for anything other than medical.
The nature of the physician-parent relationship is cited as not being conducive to the provider serving this role. Many anecdotes were shared explaining the importance to these parents of the rapport between the provider and child-parent dyad.
No. I don't feel like I have that type of relationship with my doctor where I could call and ask that [parenting advice].
Mine [pediatrician] is usually medical advice that I'm getting for whatever reason I'm bringing my child. I don't feel that there's a genuine or personal concern. To me, it's more of a routine thing for them. It would be nice, to be honest, to have a personal relationship with the physician, not personal relationship but know them and they know your kids.
Parents did not think that the doctors' medical training necessarily qualified them to give advice on the way children should be raised. When asked by the moderator, "Do you want them to give you advice outside of medical topics when you go for a check-up? You said they were all business, so would you want them to talk to you about other stuff besides the medical things?," one participant replied, "If they are knowledgeable. Just because they're a doctor, doesn't mean they know everything."
The participants thought that there were 3 limiting factors precluding the provision of parenting advice by the pediatric provider. First, there was a reported lack of time during the visit.
I think they're too busy.
Me, I would say that the doctors, I am not saying that they are all like this, but a lot of them are so rushed [group agrees], taking the next appointment, next appointment, next appointment, so they truly don't have any time. The little 10 minutes they give you, it isn't sufficient [someone mumbles that they have a lot of appointments]. Even if you were to have questions and ask for advice, they wouldn't have the time to listen to them. They are in such a rush.
Second, it was thought that the doctor's availability and the timing of parental need would not likely coincide.
She would be a last resort because I know she's not available right there when I want her to be.
Third, the provider's lack of familiarity with the family was viewed as a limitation.
They don't know the child, so how can they tell you what's good for your child when they only see that child maybe 2 or 3 times a year and they don't know the day-to-day stuff. ... I mean really, they don't know your child and they're not there with you all day long, everyday.
Even if these barriers were removed, certain core issues related to a perceived discordance between the perspectives and experiences of parents and providers may remain. Contributing to this discordance is the feeling that the providers are most often not from the participants' culture or community.
People have different customs and are raised differently and, depending on the ethnicity of the doctor, they may raise their children different from you; and I think that becomes a bind into how to raise your kid. It's not common sense, it's something that you have to learn, but I think you are better off asking your parents or your sisters and brothers or other family members or friends that are from your same ethnic background, so it's kind of consistent.
Maybe because my pediatrician is not maybe one from my community.
The mothers thought that they either did not know or did not share the child health care provider's personal value system.
To me, that is, you know,... I don't see her as having similar values and being able to understand where I am coming from in terms of my child. So I don't ask her.
I don't know anything about their value system.
They don't share their personal life with me.
And I'm pretty sure they're raising their children a little bit different from [how] I'm raising mine.
Many of the mothers thought it was important for the person giving them advice on raising their child to be a parent.
It depends on what type of parent they are. ... You know they might not even have any kids, so how are they going to tell me what's right and what's wrong? There's no blueprint on how to do this.
A lack of knowledge of the provider's value system or parenting style is compounded by a sense of distrust, which stems, in part, from the doctor's role as a mandated reporter. The parents worried that, if they were to seek advice from the provider about raising their child, then this could be interpreted as an inability to parent and could lead to removal of the child from their care.
You know what? A doctor's a doctor and you can't go talk to a doctor about everything because they're required by law to report everything. So you go talk to a doctor, you open up a whole new can of worms for yourself. And the doctor's going to smile and, in his mind or her mind, they're writing down notes.
The parents participating in this study looked to their family for advice on raising their children. The mothers in this study reported that they would go to their family to talk about various issues. When the mothers were asked, "What advice about raising your child do you ask your family for?," the responses were as follows.
Anything, everything, how to raise them, the basics.
I mean, if I'm going to go to anybody for parenting advice, it's going to be most likely the people that reared me.
[My mother] knows more than I do. She's the expert because she raised me.
Asking them for best practices; what they found worked best for them.
I know at least they can relate. You talk to somebody who knows your child.
Domain II: Doctors Can Be a Source of Parenting Advice Under Exceptional Circumstances
Although the overwhelming consensus, as presented in domain I, was that child health care providers are not a primary source of advice on raising children, there was a modest dissenting opinion. The participants conceded that some parents might be in such need of parenting help that advice on how to raise their children would have to come from unusual sources, including health care providers.
I think it depends on the maturity of the parent. There could be some parents that are actually looking for some insight. They may be at wits’ end. ... So I wouldn't want to say that a doctor should be closed off. In the same way that, as a teacher, sometimes teachers have to cross the line and tell parents how to raise their kids, although that's not what they're supposed to be doing. I'm sure that doctors need to do the same thing. I'm sure there are parents that don't even know how to feed their kids.
Some of the parents expressed that they themselves might look to the provider for advice on raising their children, as a last resort.
I think I would, and I would use her as like the last resource [with laugh] 'cause we are stressed.
She's probably the last one on my list.
A few parents from various focus groups reported that their relationship with their child's health care provider is conducive to receiving this type of advice.
I talk [about] everything, ... parenting advice ... with my doctor. ... I've known, I've been with the same doctor since my son was born. And before then I was going to him, and talking with him and getting to know him to see if he was the doctor that I wanted to entrust my children's lives with. And he's wonderful. I can call him anytime and he will call me back. ... He'll say, "How are things going? How's the home life?" We discuss everything.
Domain III: Areas Central to the Doctor's Role
The parents provided examples of areas they consider central to the doctor's role. These consist of physical health, developmental/behavioral milestones and stages, and administrative functions.
The majority of the parents consider the doctor's main role as helping them to keep their children physically healthy.
Well, I just think the pediatrician is for medical. Just stick with the medical.
Keep my infant healthy. ... Medically, that's it. ... That's it.
Parents wanted to receive even more information from the child health care provider with respect to what is developmentally appropriate at different ages.
Oh definitely. Developmental issues for sure, or landmarks to look out for.
You know, those little personality things that happen as they get older. Even when they're little, little things that they do. You know, like the "why stage" and all that other stuff, it'll drive you crazy if you don't know that that's what they're supposed to be doing [laughter]. That they're normal. That this crazy stuff is normal. I mean, I read it in a book, but to have someone reinforce it, tell you that "this is what to expect next," and not that they're going to do it literally but, you know, "this might... ." It's helpful, it's reassuring, it gives you confidence.
You know, for me it would be helpful probably to... have some advice on the... psychological development of the child, especially for the adolescent.
In addition to receiving anticipatory guidance on what to expect of their children at various ages, the parents also referred to seeking input from the child health care provider on whether their child's behavior falls within the normal range.
Behavior,... usually that's what basically is what you ask them is behavior.
On the way the child behaves.
Lastly, parents referred to the doctor's role as administrator.
That's one reason, that's another reason, but he needs physical forms to go back to school. I would call my pediatrician for that.
When school starts, they want their records, so you have to call them up just to get the records.
Discussions emphasized the importance of the relationship between providers and families. The following passage summarizes the importance to parents of a meaningful relationship.
I think I would just like for the doctor to be more open. ... While I'm there, it's only a few minutes that matters. ... Just sometimes, you know, "How are you doing?" or "How's the job?"... To really have somebody talk to me... and I can ask a question back and get an answer maybe or, I don't know, or just the face-to-face conversation, the face-to-face concern. Because it's not cheap, although the insurance pays,... yes, you're still paying. There [has] to be some type of satisfaction. And it's not always that your kid goes in and gets a shot and that's it. ... There's another reason why the kid's there. The doctor should know developmentally where your kid is and what to expect and maybe I ought to be talking about this right now. ... This doctor's not going to pan out, I don't think. Not with the routine stuff. We go in and we come out. Not that it's such a bad, bad,... it's not a bad, bad relationship, but it's very routine, it's very scheduled, and that's it.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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For a small number of parents, the pediatric provider was viewed as a resource. Two key factors seemed to determine this role. The first, and perhaps most important, was the nature of the provider-family relationship. Parents who acknowledged receiving such advice stressed their long-term, trusting relationship with their child's provider. They indicated that the provider makes time for them, makes them feel comfortable, expresses care and concern for the entire family, and shares some of their core values. The nature and impact of the parent-provider relationship have been linked to various features, including parental satisfaction,22,23 parental mood,24 provider communication, compassion, and trust,12,25,26 and provider interest, as perceived by parents.22 The second factor was parental inexperience or a lack of access to other resources. Some parents expressed the viewpoint that the provider might be a resource for those with increased needs for parenting advice or those without access to other resources (ie, a resource of "last resort").
The doctor was viewed primarily as the person with the knowledge and training to assess the child's health status and to advise parents on enhancing the child's physical health. The provision of guidance on developmental and behavioral milestones and stages and the completion of health-related forms or referrals were viewed as extensions of this health maintenance role.
The differences in parents' perspectives found in this study, compared with previous studies, may be attributable to methodologic factors or may reflect the viewpoints held by minority, compared with nonminority, parents. It is possible that, when parents are asked about the provision of parenting advice in an open-ended way, as in qualitative studies, they reflect on the concept differently, compared with when they are asked closed-ended, survey questions on the subject. Alternatively, parents from different ethnocultural backgrounds may vary in their experiences with and expectations of pediatric providers. In a recent study,27 minority and white parents differed in their reports of how well they thought their child's provider understood their child-rearing preferences. The paucity of studies using qualitative methods with samples of minority and nonminority parents makes it difficult to distinguish the specific factors that may explain our findings.
In this study, we ascertained the perspectives of several cultural groups that are often grouped together as minorities, despite their ethnocultural differences. We presented findings that were consistent across the 4 minority ethnocultural groups. Future articles will report differences among the ethnocultural groups.
The rich data collected through these focus groups could not be obtained with quantitative methods. Although qualitative data provide rich deep responses and allow exploration of such complex issues as parenting advice, several caveats should be noted. First, samples are selected randomly in quantitative studies, which yield generalizable findings; however, the qualitative study methods were chosen specifically to sample opinions of particular subgroups of ethnic minorities. Therefore, the findings may be transferable only to other samples that share the primary characteristics of the study sample. Second, although the presence of a physician (T.M.D.-M.) as an observer during the interviews ensured consistency in the organization and processes of the focus group discussions, a physician's presence might have influenced what parents chose to say about this topic.
Unlike other studies focused on providers for and parenting of children <3 years of age, this study focused on parenting and the role of the provider for children >3 years of age. The purpose of this study was to obtain the views of a sample of parents from 4 ethnocultural minority groups with preschool-aged and school-aged children. Future studies should assess whether our findings are applicable to nonminority populations with older children.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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If parenting advice is to be provided by pediatric providers, then the barriers identified in this study must first be addressed. Pediatric professionals need to demonstrate to parents that parenting advice provision is within the scope of pediatric health care. This may include making the link between expected roles such as providing advice regarding medical topics and providing advice regarding topics such as parenting. An example is linking anticipatory guidance on developmental milestones with counseling regarding discipline or safety. Providers may need to educate parents directly regarding their interest in and qualifications for undertaking this role as parenting advisor. Child health professionals also should consider providing educational materials, such as culturally appropriate pamphlets and posters on parenting issues, in their offices.
Another barrier identified is the lack of timely availability of pediatricians to families. Understandably, time is a major limiting factor in pediatric practices. However, creative solutions, such as call hours, should be considered to enhance access. A focus on maintaining continuity of care through a consistent provider may lead to an increased sense of comfort. During visits, providers may ask parents to share items that they wish to discuss by having the parents complete a previsit questionnaire while they wait to be seen. Group well-child care may help to provide an extended period for anticipatory guidance.29,30
One of the major barriers identified is a lack of parents' familiarity with providers. The well-child care visit represents an opportunity to have face-to-face conversations with the pediatric provider about issues such as the child's well-being, the parents' well-being, and the parenting experience. The doctor can indicate that she or he knows about the particular child and can express concern for the entire family.
There are no clear guidelines regarding the extent to which providers should share their personal values with parents. However, as health care providers venture into areas that overlap with value systems, a lack of familiarity with the provider's values may affect parents' willingness to engage actively in such discussions. Typically, providers are cautioned during their training not to interject their personal values and beliefs into discussions with their patients' families. However, the parents in this study expressed reluctance to seek parenting advice in part because of their lack of familiarity with the provider's values. For example, counseling parents on corporal punishment may be limited by providers' lack of acknowledgment of their personal views and practices. Simple empathetic pronouncements such as, "I've had a 3-year-old; I know it's easier said than done," may suffice. Finding ways to enhance the comfort level of families is essential.
Clarifying the role of the primary care provider may help families feel comfortable with their providers. The parents in our study expressed concerns regarding the provider's role as a mandated reporter. Providers need to define this aspect of their role, indicating what it does and does not entail. Furthermore, providers need to be nonjudgmental during their interactions with parents, both in their demeanor and in the content of their communications. If parents are not comfortable, then parenting-related discussions will likely be more difficult.
If providers are to make parents feel comfortable, then first they must be confident themselves in discussing such topics as parenting. Wissow et al31 reported that pediatric residents tended to make discouraging responses according to the type of psychosocial topic. Cheng et al32 found that physicians' attitudes about the importance of an issue and their confidence regarding their counseling were reflected in their practices. These 2 studies suggest that training and comfort are required if parenting advice provision is to be a priority within the field of pediatrics.
Unlike medical professionals, parents may rely not on evidence-based knowledge but rather on the intuition that often accompanies the experiential learning necessary for parenting. For parents, an older woman in their community who has raised a number of children successfully may have more credibility than a trained professional, such as a pediatric provider. Therefore, health care professionals must recognize the limitations of evidence-based approaches to parenting that may conflict with culturally derived values. The very acknowledgment of the value of other resources may enhance the provider's credibility with parents. In addition to acknowledging the value of the various resources, it is part of the provider's role to become familiar with these resources and to recommend them to parents as appropriate.
Schor33 suggested that it is time for a revision of well-child care. He proposed an examination of the very concept of what constitutes well-child care. Our study supports this notion and suggests specifically that both the content and the manner in which advice is provided need to be reassessed. Many questions remain. What do providers want their role to be with respect to parenting? How does that compare with what parents want us to do? Are we, as providers, psychologically ready and trained to be a primary source of parenting advice for our diverse patient populations?
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ACKNOWLEDGMENTS |
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We dedicate this article to the memory of Mrs Rasheda Ford Sinclair (moderator; d. 2004). Her professionalism, kind nature, and ready smile still remain with us today. We are grateful to all who helped facilitate this community-based research project. We appreciate that such busy mothers gave so generously of their time and shared so willingly their experiences and perspectives. We thank Frances Page Glascoe, PhD, Danielle Laraque, MD, and Ed Schor, MD, for thoughtful review of this manuscript.
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FOOTNOTES |
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Address correspondence to Thyde M. Dumont-Mathieu, MD, MPH, Department of Pediatrics, St Francis Hospital and Medical Center, 114 Woodland St, Hartford, CT 06105. E-mail: tdumont{at}stfranciscare.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
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