Factors influencing parent satisfaction with preventive health services for the early detection of speech and language delay in preschool children

doi:10.4236/ojpm.2011.13018

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Vol.1, No.3, 135-142 (2011)

doi:10.4236/ojpm.2011.13018

Open Journal of Preventive Medicine

Factors influencing parent satisfaction with preventive

health services for the early detection of speech and

language delay in preschool children*

Isabelle Bairati1,2#, François Meyer1, Cheikh Bamba Dieye Gueye1, Chantal Desmarais1,

Nancie Rouleau1, Audette Sylvestre1

1Université Laval, Quebec, Canada; #Corresponding Author: [email protected]

2Direction régionale de santé publique, Agence de la santé et des services sociaux de la Capitale-Nationale, Quebec, Canada.

Received 10 September 2011; revised 14 October 2011; accepted 26 October 2011.

ABSTRACT

The aim of this study was to identify parent and

child characteristics which could influence par-

ent satisfaction with preventive health services

designed to detect preschool children with

speech and language (SL) delay . This study was

conducted on 101 children aged 18 to 36 months

who participated in an organized SL delay early

detection program. Validated instruments were

used to assess children’s and parents’ charac-

teristics. Satisfaction was evaluated using the

client satisfaction questionnaire for the three

activities of the program: 1) a p ublic informatio n

session about SL development, 2) parent train-

ing sessions for parents concerned by their child

SL development, and 3) a child’s SL assessment.

Multiple logistic regressions w ere used to iden-

tify all independent factors (p < 0.05) associated

with satisfaction and to estimate the odds ratios

(OR) for satisfaction. Economically disadvan-

taged parents were less prone to participate in

the first two activities of the early detection pro-

gram. Older parents were more satisfied with

the public information session (OR = 1.33 for 1

year increment; p = 0.001). Distressed parents

were less satisfied with both the parent training

sessions (OR = 0.28; p = 0.009) and the SL as-

sessment (OR = 0.43; p = 0.046). Parents whose

child had health problems at birth were less sa-

tisfied with the public information session (OR =

0.14, p = 0.03) an d the SL assessme nt (OR = 0. 33,

p = 0.036). There is a need to better adapt the

delivery of preventive services for the early de-

tection of SL dela y, especially for d isadvantaged

and distressed parents and for those whose

child had suffered from health problems at birth.

Keywords: Consumer Satisfaction; Preventive

Health Services; Early Intervention; Language

Development Disorders

1. INTRODUCTION

Speech and language (SL) delay is a common deve-

lopmental problem occurring in approximately 10% -

15% of preschool children without underlying patholo-

gies [1-4]. The persistence of language problems could

compromise children’s socialization, behavior and school

performance. It is highly recommended that preventive

SL therapy interventions be initiated early in life. Ac-

cording to a meta-analysis, SL therapy interventions are

effective in children with phonological or vocabulary

difficulties [3]. Yet, accessibility to SL therapy services

remains a major concern in several communities [4,5]. A

SL therapy program was implemented in primary health

centers in the Quebec City area with early detection of

SL delay as one of its main component.

Parental involvement is an important element in chil-

dren’s early intervention programs [6-8]. Parents play a

central role by using relevant community services and by

complying with early intervention programs. They are

generally targeted to take an active role in the SL ther-

apy interventions since children generally learn language

most efficiently in their natural environment. In addition,

parent satisfaction with their child’s medical services has

been reported to be associated with therapy adherence

and health improvements [9-11]. This underscores the

importance to tailor SL preventive services according to

the needs of the parents.

Parent satisfaction with care is a measure of quality of

care [12-14]. Satisfaction refers to the degree to which

parents perceive that the services meet their needs and

those of their child. This perception might reflect par-

ents’ expectations and their personal preferences. Less is

known about the parent and child features which could

*Supported by a grant from the FRSQ.

I. Bairati et al. / Open Journal of Preventive Medicine 1 (2 011) 135-142

136

influence satisfaction with care. Several studies sug-

gested that satisfaction with services might be influenced

by parental distress, type and severity of the child’s dis-

ability and the child’s lack of improvement [15-17]. The

aim of this study was to identify parent and child char-

acteristics which could influence parent satisfaction with

preventive services designed to detect SL delay early in

life.

2. METHODS

2.1. Participants

This satisfaction survey was conducted as part of a

cohort study designed to identify predictors of persistent

language disorder among children with language delay.

The study was approved by the Laval University re-

search ethics committee. Written informed consent was

obtained from the parents. Eligible children were aged

between 18 and 36 months and had received a clinical

diagnosis of language delay by a SL pathologist at the

time of their language assessment in the SL delay early

detection program. Children with associated pathologies

already detected at the time of recruitment, such as

Down syndrome or a known neurological pathology,

were not eligible. Only one child per family was allowed

to participate in the study. All children were recruited in

the study between February 2005 and November 2006 in

ten primary health centers of the Quebec City area.

2.2. Speech and Language Delay Early

Detection Program

The main goal of this program is to offer early detec-

tion of SL delay in preschool children. This publicly

funded program was developed according to a model of

preventive interventions for mental disorders [18]. The

program was implemented in 1999 in community based

medical services in the area of Quebec City. The pro-

gram is conducted at least three times per year and com-

prises three main activities (Figure 1).

The first activity, an universal preventive intervention

[18], is a public information session offered to the ge-

neral population. Its main goal is to raise awareness

among a large public audience regarding language de-

velopment. Announcements of these public information

sessions are done via local journals, day care centers,

social services, and medical clinics. The participants are

generally families and health or early education profess-

sionals. During these sessions, the SL pathologists give

extensive information about the typical language devel-

opment according to chronological age. They also indi-

cate some strategies to reinforce the quality of the lan-

guage stimulation that parents offer to their children.

Public

Information

Sess ion

Parent

Training

Sessions

Speech and

Language

Assessmen t

Identification

of Eligible

Children

Entry in the

Study

Home Visit

Satisfactio n

Survey

2 weeks2 weeks

Activities of the Study

Activities of the Program

Figure 1. Timeline of activities in the program and in the

study.

Finally, they answer questions from the audience. At the

end of the session, parents who are still concerned by

their child language development are invited to register

for the second activity.

The second activity, an indicated preventive interven-

tion [18], consists of three parent training sessions. The

objectives of this activity, led by the SL pathologists, are

to reinforce parents’ competencies through counseling

and guidance techniques; to help parents enhance the

quality of stimulation provided to their child; and to pro-

mote exchanges between parents. The SL pathologists

explain and demonstrate methods of optimal language

simulation. During this activity, parents are given the

opportunity to share their skills, concerns, and feelings.

The third activity, which takes place around the end of

the second activity, is an individual assessment of the

child’s language development by one of the program SL

pathologists. This assessment is based on a direct obser-

vation of the child in a play situation and of the child

interactions with both the therapist and the parents. This

individual assessment is mandatory to have further as-

sessments and interventions.

2.3. Data Collection

Baseline data collection was done two weeks after the

SL assessment during a two hour home visit (Figure 1).

A first trained research assistant interviewed the parent

in charge of the child at the time of this home visit (the

index parent) while a second assistant tested the child.

The procedures done and the questionnaires used during

this home visit have been described in a previous publi-

cation [19].

Briefly, structured questionnaires were administered

to the index parent in order to evaluate their socio-

demographic status, the medical history of each member

of the family, and the obstetrical history of the mother.

In addition, validated instruments were used to investi-

gate parental stress and resources. The Parenting Stress

Index (PSI)—Short Form was used to evaluate parental

I. Bairati et al. / Open Journal of Preventive Medicine 1 (2 011) 135-142

137

distress, difficult child characteristics, and dysfunctional

parent-child interaction [20]. Based on these three di-

mensions, a total stress index was generated. The Per-

ceived Adequacy of Resources Scale (PARS) was ad-

ministered to assess how parents felt about the adequacy

of their resources [21]. Four domains were retained: time,

financial, interpersonal and health/physical energy. The

parent completed the Child Behavior Checklist (CBCL)

to rate various child behavioral and emotional problems

[22].

Child language expression and comprehension were

tested using the Rossetti Infant Toddler Language Scale

(ITLS) [23]. This instrument, commonly used in clinical

settings, is designed to evaluate the communication skill

of children according to their age categories. Scores

were generated according to the method proposed by

Desmarais et al. [19]. The Bayley Scales of Infant De-

velopment (BSID-II) was administered to measure child

mental and motor development [24]. In addition, parents

were invited to evaluate the severity of their child’s lan-

guage difficulty using a 7 point Likert scale.

The satisfaction survey was conducted over the phone

by a trained interviewer approximately two weeks after

the home visit. Satisfaction assessment for each of the

three activities of the program was sought from the par-

ent who participated in the given activity. Parents’ gen-

eral satisfaction was assessed using the client satisfac-

tion questionnaire (CSQ)-3 items [12]. The score of gen-

eral satisfaction ranged from 1 (low satisfaction) to 4

(high satisfaction). The CSQ-3 items have already been

used to assess parent satisfaction with pediatric services

and children’s rehabilitation services and shows good

internal consistency (Cronbach’s alpha of 0.83 - 0.85)

[25-27].

2.4. Statistical Analyses

Pearson’s chi-square tests were used to identify par-

ents and child characteristics that differed between par-

ents who took part in the activity and those who did not.

The three satisfaction scores were dichotomized accord-

ing to the median of their distribution. Parents were con-

sidered “satisfied” if their mean score of satisfaction was

above 3.5, otherwise they were classified as “relatively

dissatisfied”. Associations between parent satisfaction

and baseline characteristics of the parents and their child

were evaluated using logistic regression [28]. All the

scores generated from validated instruments, such as the

total parenting stress index, the Bayley scores, and the

CBCL scores, were dichotomized according to the clini-

cal recommendations. When clinical norms were not

available, scores were dichotomized according to the

median value. Variables associated with parent satisfac-

tion (p ≤ 0.15) in bivariate analyses were considered for

inclusion in the multiple logistic regression models. A

forward selection procedure was used to build the mul-

tivariate models by entering at each step the variable the

most significantly associated with satisfaction. All vari-

ables retained in the final models were significantly as-

sociated with satisfaction (p < 0.05). Odds ratios (OR)

and their 95% confidence intervals (CI) were generated.

3. RESULTS

A total of 10 primary health centers in which the pro-

gram was offered collaborated to the study. Following

the SL assessment of the child (third activity of the pro-

gram), the SL pathologists invited 191 consecutive po-

tentially eligible parents to participate in the study. Of

these, 102 parents and their children were enrolled and

101 parents completed the satisfaction survey. The re-

fusals were mostly due to lack of time. The distribution

of demographic and medical characteristics of the par-

ents and their children are presented in Table 1.

Table 1. Characteristics of the 101 children and their parents

participating in the speech and language delay early detection

and intervention program.

Characteristics of the children

Age—months—m (SD) 29.3 (4.4)

Sex - male—n (%) 72 (71.3)

Being the eldest child—n (%) 51 (50.5)

Living in a single-unit housing—n (%) 74 (73.3)

Ever attended a day care facility—n (%) 90 (89.1)

Health problems at birtha—n (%) 21 (20.8)

Language expression scoreb—m (SD) 59.9 (24.9)

Language comprehension scoreb—m (SD) 77.7 (20.2)

At risk of mental delayc—n (%) 46 (46.0)

At risk of motor delayc—n (%) 39 (38.6)

Behavioral problemsd—n (%) 12 (12.6)

Characteristics of the parents

Age of the index parent - years—m (SD) 32.3 (4.4)

Parental role of the index parent—n (%)

Mother

91 (90.1)

Marital status of the biological parents—n (%)

Married

93 (92.1)

Family annual income—n (%)

≥ $ 60,000

54 (53.5)

Education level of the mother—n (%)

Primary school

Secondary school

Post-secondary school

3 (3.0)

21 (20.8)

77 (76.2)

aIncludes low birth weight (<2500 g), prematurity (<37 weeks), congenital

malformation, and referral to a specialized unit at birth. bAccording to the

Rossetti Infant Toddler Language Scale (the scores are from 0 to 100:

higher scores correspond to higher levels of expression or comprehensive

language). cAccording to the Bayley Scales of Infant Development (scores

<85 indicate children at risk for developmental delay). dAccording to the

Child Behavior Checklist (a total score > 90th percentile of the distribution

of a reference population indicates children with behavioural problems).

I. Bairati et al. / Open Journal of Preventive Medicine 1 (2 011) 135-142

138

Of the 101 parents, 75 parents took part in the public

information session (Table 2). The proportion of par-

ticipation varied from 10% to 100% according to the

primary health centers (p = 0.0001). The primary health

center with the lowest proportion of participants (10%)

serves an economically disadvantaged population. Par-

ticipation rate in the public information session was

higher among families with a higher socio-economic

profile. None of the other parent and child characteristics

(e.g. parental distress, child development) were signify-

cantly associated with participation in this first activity.

Among the 101 parents, 83 parents participated in the

parent training sessions. Similarly, participation varied

according to the primary health center (from 20% to

100%, p < 0.0001) and the family socio-economic pro-

file.

The median values of the satisfaction scores were 3.5

for each of the three program activities. The internal

consistency of the scores varied between 0.78 and 0.82.

Parent satisfaction with the public information session

was significantly and independently associated with

three factors (Table 3). Greater satisfaction was reported

when the parents were older, the mother had a history of

miscarriage, and when the child did not have health

problems at birth. Two parental characteristics were in-

dependently associated with satisfaction regarding the

parent training sessions (Table 4). Parents were more

satisfied when the father did not work full time and

when there was less parental distress. Two factors were

independently associated with parent satisfaction re-

garding the child’s SL assessment (Table 5). Greater

satisfaction was reported when the child did not have a

health problem at birth and when there was less parental

distress. Neither the type of language delay (expressive

Table 2. Participation rates in the public information session and the parent training sessions according to the parents’ socioeconomic

status.

Study population (N = 101)

Public information session (75 participants) Parent training sessions (83 participants)

Characteristics Participants/Total (%) P-value Participants/Total (%) P-value

Family annual income

<$ 60,000

≥$ 60,000

30/47 (63.8)

45/54 (83.3)

0.025

36/47 (76.6)

47/54 (87.0)

0.17

Living in a single-unit housing

Yes

15/27 (55.6)

60/74 (81.1)

0.009

18/27 (66.7)

65/74 (87.8)

0.014

Mother employment status

Full time

Other status

38/46 (82.6)

37/55 (67.3)

0.08

42/46 (91.3)

41/55 (74.6)

0.03

Mother education

Primary or secondary school

Post-secondary school

12/24 (50.0)

63/77 (81.8)

0.002

14/24 (58.3)

69/77 (89.6)

0.0005

Table 3. Factors associated with parent satisfaction regarding the public information session.

Bivariate analysis Multivariate analysis (n = 73)

Factors No. of satisfied subjects/N (%) OR P-value OR 95% CI P-value

Age of the index parent (continuous)

-/75

1.30

0.0001

1.33

1.12 - 1.58

0.001

Annual familial income (CDN $)

<60,000

≥60,000

11/30 (37)

25/45 (56)

1.00

2.16

0.11

Eldest child

Yes

21/35 (60)

15/40 (38)

1.00

0.40

0.05

Child with health problems at birtha

Yes

33/60 (55)

3/15 (20)

1.00

0.20

0.01

1.00

0.14

0.03 - 0.82

0.03

Mother history of miscarriage

Yes

20/51 (39)

16/22 (73)

1.00

4.13

0.008

1.00

9.63

1.96 - 47.43

0.005

Total stress index of the index parentb

Normal

High

29/65 (45)

7/10 (70)

1.00

2.90

0.13

aIncludes the following problems: low birth weight (<2500 g), prematurity (<37 weeks), malformation or referral in a specialized service at birth. bAccording to

the Parenting Stress Index (a total index ≥ 90 indicates a high level of stress).

I. Bairati et al. / Open Journal of Preventive Medicine 1 (2 011) 135-142

139

Table 4. Factors associated with parent satisfaction regarding the parent training sessions.

Bivariate analysis Multivariate analysis

Factors No. of satisfied subjects/N (%) OR P-value OR 95% CI P-value

Sex of the parent

Female

Male

32/76 (42)

6/7 (86)

1.00

8.25

0.02

Father employment status

Full-time

Other status

29/70 (41)

8/10 (80)

1.00

5.65

0.02

1.00

5.80

1.08 - 31.2

0.04

Living in a single-unit housing

Yes

12/18 (67)

26/65 (40)

1.00

0.33

0.04

Eldest child

Yes

22/40 (55)

16/43 (37)

1.00

0.49

0.10

Only child

Yes

31/59 (53)

7/24 (29)

1.00

0.37

0.05

Behavioral problems of the childa

Yes

28/69 (41)

6/8 (75)

1.00

4.39

0.08

Parental distress of the index parentb

Yes

26/42 (62)

12/41 (29)

1.00

0.26

0.004

1.00

0.28

0.11 - 0.73

0.009

aAccording to the Child Behavior Checklist ( total scores of more than the 90th percentile of a reference population indicate behavioral problems). bAccording to

the Parenting Stress Index (a score higher to the median indicates higher levels of parental stress).

Table 5. Factors associated with parent satisfaction regarding the child speech and language assessment.

Bivariate analysis Multivariate analysis

Factors No. of satisfied subjects/N (%) OR P-value OR 95% CI P-value

Sex of the parent

Female

Male

47/88 (53)

10/13 (77)

1.00

2.91

0.10

Eldest child

Yes

33/50 (66)

24/51 (47)

1.00

0.46

0.05

Child with health problems at birtha

Yes

50/80 (63)

7/21 (33)

1.00

0.30

0.02

1.00

0.33

0.12 - 0.93

0.036

Parental distress of the index parentb

Yes

35/52 (67)

22/49 (45)

1.00

0.40

0.02

1.00

0.43

0.19 - 0.98

0.046

Dysfunctional interaction between the

index parent and the childb

Yes

32/48 (66.7)

25/53 (47.2)

1.00

0.45

0.05

aIncludes the following problems: low birth weight (< 2500 g), prematurity (< 37 weeks), malformation or referral in a specialized service at birth. bAccording

to the Parenting Stress Index (scores higher to the median indicate higher levels of parental stress or higher dysfunctional parent-child interactions).

or receptive), nor the degree of severity of the language

delay, was associated with parent satisfaction for any of

the three activities of the early detection program (data

not shown).

4. DISCUSSION

Overall, parent satisfaction with each activity of the

SL delay early detection program was high. However,

parents with high levels of distress and those whose

child had health problems at birth were consistently less

satisfied with the program. This study also showed that

economically disadvantaged parents were less prone to

participate in the activities of the program with educa-

tional components.

One strength of this study was measuring the general

I. Bairati et al. / Open Journal of Preventive Medicine 1 (2 011) 135-142

140

satisfaction using a validated instrument [12] while most

studies evaluating parent satisfaction regarding SL pro-

grams have elaborated their own satisfaction question-

naires. Our results, as well as those of other studies

[25-27], showed that the CSQ-3 items have a good inter-

nal reliability for measuring general satisfaction of par-

ents. A common phenomenon of the surveys evaluating

satisfaction, including ours, is to produce highly skewed

distribution of the satisfaction towards higher levels of

satisfaction [14,16,17,25]. This ceiling effect could have

occurred in our study because the range of the four-point

Likert scale used with the CSQ-3 was probably not

broad enough to detect satisfaction variations among

individuals with high levels of satisfaction [29]. Oral

administration of the CSQ has been reported to produce

10% higher satisfaction ratings than written administra-

tion in clients with psychiatric problems [30]. This result

is mainly explained by the fact that oral administration

of the satisfaction questionnaire is usually carried out by

the medical staff and/or at the time of the delivery of

care. In our study, it is doubtful that the reason of high

level of satisfaction was due to the method of admini-

stration because satisfaction assessment was done by

phone after the end of the third activity of the program

and by a university research assistant who had no link

with the program.

Our study population is among the largest cohort

studies of children with language delay. All participating

parents, except one completed the satisfaction survey.

Comparisons of the characteristics of participating par-

ents whose child had a SL assessment but did not par-

ticipate in the two first preventive activities showed that

economically disadvantaged parents were less prone to

participate in these preventive activities. As the health

system in the province of Quebec is publicly funded,

reasons for non-participation by parents in these pro-

gram activities are unlikely to be solely financial in na-

ture [31]. Several actions are undertaken by the program

SL pathologists to reach economically disadvantaged

parents according to recognized approaches [32]. These

actions, called selective preventive interventions [18] in

the program, varied according to the features of the

populations deserved by the primary medical centers in

which the program is implemented. These selective in-

terventions are generally undertaken in collaboration

with community-based organizations and other existing

preventive programs. Parents identified through these

actions could be offered to directly participate in the

second or the third activity of the program. Yet, it is dif-

ficult to identify parents referred to the program via the

selective preventive interventions and the effectiveness

of these activities remains to be evaluated. In the present

study, the fact that economically disadvantaged parents

were less prone to participate in the first two preventive

activities could have hindered some associations be-

tween socio-economic factors and parent satisfaction.

However, a review reported that no consistent relation-

ship could be observed between socioeconomic status

and satisfaction with medical services [13].

Older parents recorded higher satisfaction with the

public information session. The association between age

and satisfaction is consistently reported in the literature

and might be due to lower levels of expectations in older

consumers of services [13]. The same reason could ex-

plain why parents were more satisfied with the public

information session when the mother reported having

had reproductive difficulties. The parent training session

appeared to be appreciated when the father had not a

full-time job. It is understandable that the availability of

parents is necessary for ensuring their participation in

these sessions. A history of health problems at birth,

such as prematurity, low birth weight, affected the satis-

faction of parents regarding both the public information

and the SL assessment. Since the SL delay early detec-

tion program is a community program, these parents

could have perceived that their child did not receive the

services and/or medical follow-up required after their

child’s initial health problem.

Distressed parents were dissatisfied regarding both the

parent training session and the SL assessment. Several

studies support an inverse association between high lev-

els of parental distress and satisfaction with their child’s

care [15,33,34]. SL assessment might be perceived by

the parents as a judgment. In addition, the first commu-

nication of a suspected diagnosis of disability may be

done at the time of the assessment, when confidence

between parents and therapists is not yet well established.

This experience could have a high emotional impact on

distressed parents and consequently on their satisfaction.

Furthermore, distressed parents may have difficulty

communicating concerns and asking questions, particu-

larly when they receive new information. Brown et al.

[35] showed that mothers reported higher satisfaction

with child’s pediatric primary care providers when their

own stress was discussed during pediatric visits. Overall,

this suggests that parental stress might also be a topic

worth formally addressing during the program activities.

The US Preventive Services Task Force recommended

that optimal methods of screening for SL delay should

be established, in particular with regards to the timing of

assessment and the instruments used [36]. Beyond this

preoccupation, our study shows that there is a need to

better define the approach used to reach vulnerable

populations for early detection of SL delay and to think

further about how to share this experience between fa-

milies and professionals.

I. Bairati et al. / Open Journal of Preventive Medicine 1 (2 011) 135-142

141

5. ACKNOWLEDGEMENTS

We thank all the SL therapists from the program who invited fami-

lies to participate in the study.

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