Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 3 Issue: 1

Childcare Responsibilities and Women's Medical Care

Jason R Woloski, Candace Robertson-James*, Serita Reels and Ana Núñez
Women’s Health Education Program, Drexel University College of Medicine, Philadelphia, Pennsylvania 19129, USA
Corresponding author : Candace Robertson-James
Women’s Health Education Program, Drexel University College of Medicine, 2900 Queen Lane, Suite 228, Philadelphia PA 19129, USA
Tel: 215-991-8450; Fax: 215-843-0253
E-mail: [email protected]
Received: June 29, 2013 Accepted: December 31, 2013 Published: January 06, 2014
Citation: Woloski JR, James CR, Reels S, Núñez A. (2014) Childcare Responsibilities and Women’s Medical Care. J Womens Health, Issues Care 3:1. doi:10.4172/2325-9795.1000133

Abstract

Childcare Responsibilities and Women’s Medical Care

Caring for children requires an ongoing commitment to their provision, growth and development, which may require balancing multiple demands and a personal sacrifice at times. While both men and women are impacted by childcare responsibilities, women are often viewed as the primary managers of their children’s care and, in general, spend as much as 50% more time providing care than their male counterparts.

Keywords: Women's health; Childcare; Healthcare barriers

Keywords

Women’s health; Childcare; Healthcare barriers

Introduction

Caring for children requires an ongoing commitment to their provision, growth and development, which may require balancing multiple demands and a personal sacrifice at times. While both men and women are impacted by childcare responsibilities, women are often viewed as the primary managers of their children’s care and, in general, spend as much as 50% more time providing care than their male counterparts [1,2]. Mothers provide the sole or primary source of income in 40% of households with children, of which 63% are single mothers who have a median income of $23,000 [3]. In addition, pregnancies to women over age 30 have continued to increase [4], suggesting that women are maintaining their childcare responsibilities as they age and their risk for a number of chronic diseases increases. Moreover, 10% of children live with a grandparent, 41% of which are being raised primarily by that grandparent. Furthermore, over 60% of grandparent caregivers are female [5]. Lastly, 66% of family caregivers are women, 37% of which have children or grandchildren under 18 living with them. More than half of caregivers report delaying care practices such as skipping a doctor’s appointment [6]. For this reason, attention to women’s health and barriers to health care access is an important issue of concern, especially given women’s important role as caretakers for their children and families [1].
An estimated fourteen percent of women have a limiting disability, health condition, or handicap [7]. Moreover, thirty-eight percent of women, in contrast to thirty percent of men, have a chronic condition requiring ongoing medical attention [7]. Income plays a role, with low-income women almost three times more likely to report fair or poor health [7]. African American women, in comparison to White and Latina women, have higher rates of arthritis, hypertension, and heart disease [1]. Women are also more than twice as likely as men to report depression or anxiety [7], hence the importance of adequately addressing potential barriers to timely and appropriate medical care by women.
Prior research has identified several barriers to women’s healthcare access. These include lack of insurance, healthcare costs, time (busy schedule), work commitments, and transportation problems [7-9]. For instance, women are more likely to report delaying or forgoing medical care due to healthcare costs and logistical barriers such as inconvenient hours, office room wait time and an inability to get an appointment soon enough [9]. However, despite the many barriers that may prevent or delay women from accessing medical care that have been previously identified, a minimal amount of studies explore the potential role of childcare responsibilities on women’s health care decisions, especially when faced with potential emergent health concerns. For example, the logistical barriers explored above did not include childcare responsibilities, which may influence women’s perceptions of convenient hours, office room wait time and availability of appointments.
A Kaiser survey reported that 13% of women stated they delayed or omitted care because of problems with childcare [1]. Moreover, some studies have suggested an association between caring for children and health practices. For instance, the risk for noncompliance with home antiretroviral therapy among women has been shown to increase significantly for each child at home younger than 18 years of age [10]. Similarly, studies have shown childcare obligations to be significantly associated with a delay in diagnosis of women who are experiencing cancer symptoms [11]. A study from the United Kingdom showed a clear relationship between the number of children a woman had and her ability to exercise [12]. This observation is concerning, as exercise is an important factor in preventing many health conditions in women, including heart disease and stroke [13,14]. While there are several health promotion initiatives promoting fitness in families, this underscores the challenges felt by many women balancing the responsibility of caring for their children and engaging in preventive activities such as routine physical fitness.
In 2010, nearly one in four children (~25%) lived only with their mothers, whereas only 3% lived only with their fathers [15]. Furthermore, the estimated number of children in the United States is expected to increase in the future, thus potentially increasing the number of women facing childcare barriers. In 2011, there were 73.9 million children ages 0 to 17 in the United States, or 24% of the population [16]. It is projected that by 2050, the number of children ages 0 to 17 will increase to 101.6 million [16]. This issue is further confounded by a rise in economic hardships, which are forcing more women into the workforce. According to the U.S. Bureau of Labor statistics, among the 34.6 million families with children in the year 2012, 87.8 percent had at least one employed parent, up slightly from 87.2 percent in 2011 [17]. The mother was employed in 67.1 percent of families with children maintained by women with no spouse present in 2012, and the father was employed in 81.6 percent of families with children maintained by men with no spouse present [17]. As a result of work demands, parents will need to find alternative caregivers for children, including relatives and friends. Thus, individuals acquiring these childcare responsibilities may also, in turn, have their health care seeking behavior altered.
While there is a dearth of research on the role of childcare responsibilities on women’s healthcare practices, it is essential for healthcare providers to further understand the role of these responsibilities as a potential barrier to women’s health. As a result, health care professionals and patients can work together to overcome hurdles, including but not limited to, the development of an emergency action plan outlining alternatives for childcare services in the case of a personal health emergency. This study served three main purposes. The first aim was to further understand the number of women delaying medical care secondary to childcare responsibilities in a community based sample. The second aim was to investigate the role of childcare responsibilities in women’s healthcare, including both routine and emergent care, using a qualitative methodology. Lastly, we aimed to provide recommendations to assist physicians and other health care providers in discussing the role of childcare responsibilities with their patients. This research was conducted as part of a community needs assessment in Philadelphia, PA, aimed at identifying priority areas for women’s and girls’ health [18].

Materials and Methods

This research utilized a sequential explanatory mixed methods design in which quantitative data collection and analysis were completed first, followed by qualitative data collection and analysis [19]. The study protocol was approved by the university institutional review board.
Quantitative component
The quantitative component consisted of the secondary data analysis of two surveys, a local community based survey and the Southeastern Pennsylvania Household Health Survey. The community needs assessment survey was implemented with 160 women, 18 to 84 years of age (M=38), recruited from community partner sites, including local schools, health, wellness, faith based and social service organizations. This needs assessment is described more comprehensively in a subsequent publication by Dr. Núñez and Colleagues [18]. Racial and ethnic characteristics of the respondents included white/Caucasian, 38.4%; black/African American, 37.1%; Latina, 8.8%; Asian/Pacific Islander, 10.1%; biracial, 4.4%; other, 1.3%. Most participants reported having some type of health insurance (4% uninsured). Additional demographic characteristics of participants are reported in the overview needs assessment article [18]. The survey was administered in a paper format with participants recruited by the aforementioned partnering sites. The anonymous survey assessed basic health care practices and included questions assessing reasons women delay care. The survey asked women to identify reasons they delay care and to rank the reasons in order of importance. Descriptive statistics of demographic variables as well as key study variables were reported. Additionally, bivariate comparisons were made between delay in seeking care and number of children, as well as other variables.
The Southeastern PA (SEPA) Household Health Survey is a telephone survey of more than 10,000 households in the Philadelphia metropolitan area [20]. The survey uses a random digit dial method and is implemented as part of the Community Health Database. Survey topics include health status, health behaviors, access to care, screenings, insurance, and other health-related indicators. A secondary analysis of the data from the 2010 SEPA Household Health Survey was used to explore relationships between the number of children women care for and health care behaviors, such as accessing care. The analysis included 6597 women. The mean age of women was 53 years. The racial and ethnic characteristics of respondents included white/Caucasian, 67%; black/African American, 23%; Latina, 5%; Asian, 2%; biracial, 2%; and other, 1%. Bivariate comparisons were also made to relevant study indicators such as access to care and number of children caring for. Statistical analysis of all quantitative data was performed using SPSS. The quantitative component was completed first and was used to inform the qualitative component described below.
Qualitative component
The qualitative component included key informant focus group interviews implemented with 34 women (mean age=47), including health care providers, educators, church leaders, administrators, business professionals, and community and social service agency leaders to discuss the role of childcare responsibilities as a barrier to delaying medical care. Racial and ethnic characteristics of the respondents included White/Caucasian (32.4%) and Black/African American (67.6%). These adult women, 18 years of age and older, were recruited from community partner sites (described above) by study flyers. Interested informants contacted project team members to participate. Interviews were conducted at partner sites in a group setting using a standard focus group methodology [21]. A total of five focus groups were held, each ranging from four to ten participants. Group interviews were implemented with women of similar stakeholder groups in order to assist in identifying similarities among women with common vocations, including educators, healthcare workers, businesswomen and faith based organizations. Examples of the guiding questions used for the focus group discussions include the following: There are many reasons why women delay medical care. In your opinion, what are some of the reasons women delay care? Do you think there is a difference between the reasons women with childcare responsibilities delay routine versus emergency care? Aside from delaying care, what do you believe are some other ways in which childcare responsibilities can impact a woman’s health?
A full list of guiding questions is provided in Appendix 1. The focus groups were held for approximately 90 minutes each. Key informants spoke from their professional and personal experiences. A 10 question multiple choice questionnaire containing both demographic and delay of care questions was also completed by each focus group participant, including questions regarding participant attitudes and perceptions related to seeking medical care and childcare responsibilities.
The same focus group facilitator was used for all focus group sessions and each session was audiotaped. The audiotapes were transcribed verbatim and reviewed by three investigators (two with specific expertise in women’s health and qualitative research) to identify major themes and supporting quotations. Content analysis was conducted and major themes were identified. A list of apriori codes was initially established based on the question domains [22]. These included the role of healthcare providers in discussing childcare responsibilities with patients and the role of childcare friendly facilities for example. Additional codes were identified as the transcripts were reviewed. Any themes that did not have initial agreement between the investigators were discussed and the transcripts were reviewed again for the specific area of disagreement. The additional reviews and discussion was used to reach consensus on the final themes that emerged [22,23]. The multiple reviews of the transcripts and discussions among investigators to gain consensus and identification of supporting quotations for each theme were used to reflect the validity, trustworthiness and confirmability of each theme [24].

Results

Quantitative component
SEPA household health survey: As described above, the SEPA Household Health Survey was analyzed in order to explore relationships between the number of children women care for in their households and health care behaviors such as accessing care. Overall, 29% (n=1900) of women reported between 1-3 children cared for in their household. The mean number of children cared for in households decreased with participant age (women aged 18-39: M=1.39, SD=1.46; 40-49: M=1.25, SD=1.34; 50-59: M=.32, SD=.782; 60-74: M=.10, SD=.666). Although older participants were less likely to report caring for children in their households, survey respondents reported between 0-10 children, indicating that older women are caring for children in their households. The survey was also used to evaluate the relationships between numbers of children in households women were caring for and health care and financial insecurity indicators. According to t test results, women who reported caring for more children in their households were more likely to be sick and to not seek care due to cost (p<.01); not fill a prescription medication due to cost (p<.01); and not seek dental care due to cost (p<.01). Women who reported caring for more children in their households were also more likely to be receiving food stamps (p<.01), WIC benefits (p<.01), and Temporary Assistance for Needy Families (TANF) benefits (p<.01) and to report cutting a meal due to lack of money (p<.01). No significant relationship was found between the number of children women were caring for and the diagnosis of chronic diseases such as hypertension or diabetes.
Community needs assessment survey: Results from the community needs assessment survey of 160 adult women indicate that 13% of all women surveyed reported delaying care due to childcare responsibilities within the past year. Of participants who reported delaying care, women with more than 2 children were most likely to report delaying care (Figure 1). Of note, among the women who reported delaying care due to childcare responsibilities, 19% of these women had grown children and 28.6% were without children, indicating that women are often responsible for caring for others’ children as well as their own. No statistically significant association was found between marital status and delaying care due to childcare responsibilities.
Figure 1: Parturition characteristics of women who reported delaying care due to childcare responsibilities.
Qualitative component
Results from the questionnaires completed by the 34 key informant interview participants, highlighting participant attitudes and perceptions related to seeking medical care and childcare responsibilities, are presented in Figure 2. Parturition and delay of care data for the informants are highlighted in Figure 3. Overall, most informants had children of their own and many reported delaying preventive care (47%) as well as emergent care (21%) for themselves in the past year.
Figure 2: Key informant awareness and perceptions related to seeking medical care and childcare responsibilities.
Figure 3: Key informant questionnaire respondents parturition characteristics and delay of care.
Five major themes regarding the role of childcare responsibilities in delaying preventive, routine, and emergent care were identified from the interviews with the key informants. The quotations used below in support of the themes represent verbatim responses from the women who participated in the interviews.
Theme 1. Financial burdens associated with seeking medical care: The key informants discussed their perceptions that women often do not go for medical care because they do not have the financial resources to pay the copays or lack insurance and cannot afford outof- pocket costs. Women discussed how the added responsibility of caring for children increases financial obligations which influences healthcare practices. As economic resources are limited, children’s needs are often prioritized over their own. In addition, missing work is not an option for many women due to the need for the paid time. As one church parishioner stressed, “Many women are choosing between buying food and accessing health care”. Women often prioritize their children’s needs over their own and forfeit their personal care. “I’m more concerned with what is going on with them (her children)”, another parishioner announced. However, similar viewpoints were expressed by informants in all of the focus groups, including women speaking on behalf of working, lower and middle class women and from multiple diverse groups.
Theme 2. Noncompliance can be attributed to logistics of obtaining medical care: Participants discussed many barriers to seeking care related to women’s childcare responsibilities, including the logistics and time involved with the health care encounter. A quote by a local businesswoman summed up the views of many women across multiple focus groups when she remarked, “going to the doctor is an all-day experience”, and “women have to be cautious of how much they call out from work since taking care of yourself and going to doctor appointments can potentially cost you a job”. Many informants stated that women often use available sick days when their children are sick so they may not have any available for their own use. This is especially problematic for women who hold part-time jobs or service industry jobs that may not provide any or a limited number of sick days in the first place. Similarly, women may be reluctant to use sick days for their own use in order to save them to spend time with their children. Furthermore, childcare centers were discussed as a barrier, due to the hours often available for medical appointments conflicting with hours childcare centers are open. Childcare facilities often charge late fees if children are not picked up on time, which may additionally influence women’s delay of care and feeling limited regarding when they can schedule appointments. Participants also felt that even if free time could be arranged, it would be used for quality time with the children. Women would be more likely to use the limited free time available for activities with their children rather than scheduling medical appointments. For instance, one administrative assistant at a local school remarked, “You are already juggling so much that you feel any free time is theirs (referring to the children)”. Suggestions for overcoming such issues included extending office hours to include late afternoon, evening and weekend hours. Informants also suggested that employers could assist by offering an allotment of “child sick days” to employees that would be separate from women’s own sick days.
Lastly, participants discussed how the logistics involved with caring for children and taking the children with them to seek care often influences women’s decisions to delay care. A biomedical researcher shared that she had cut her leg and resorted to using a towel to control the bleeding because she was alone and could not feasibly take her three children, two of whom were toddlers at the time, to the emergency room. When asked if she would have handled the situation differently if she had not had the children with her at the time, she answered, “I would have gone to the ER. It needed to be stitched up and now I have this scar”.
Theme 3. Healthcare Providers can assist by inquiring about childcare responsibilities: The informants discussed how women may often feel isolated as they struggle to balance their children’s needs with their own. For instance one church parishioner remarked, “Women are natural nurturers… they take care of everyone else except themselves … the caretaker suffers more than anyone else and they suffer in silence”. Therefore, it was suggested that health care providers could play a role by simply asking the question about childcare responsibilities in order to start a “spark” and help women evaluate their barriers to accessing care. By asking women about childcare responsibilities and the role of these responsibilities in their health, providers may be able to help women identify and address a significant barrier. Participants discussed a more patient centered approach to care, in which providers seek to identify and address potential barriers. A local educator remarked, “If the doc wants you to be more compliant, they should find out the reason (you’re not compliant) … goes hand in hand with being a good doctor”.
Relatives often take care of other family members’ children, and women often assume the role of a babysitter for others’ children, further underscoring the importance of understanding the role of childcare responsibilities in women’s health care. The key informants agreed that health care providers should explore childcare responsibilities with all women, including patients who do not have children of their own, because they may be caring for other children. One woman working in the healthcare industry remarked, “I think they should still ask the question … in the times we are living in today, you can’t assume anything”. The informants agreed that asking the question of all women would help break this silence and isolation and help women to partner with providers to address this barrier in seeking care.
Theme 4. Secondary caregivers are also reluctant to seek medical care: The informants discussed that many women also care for other’s children, which further causes them to delay seeking medical care, particularly in emergent situations. For example, a university employee stated, “When you take care of someone else’s kids you are responsible for their wellbeing and health so your own health takes a back seat”. In addition, when in the role of the secondary caregiver it is challenging to find a caregiver alternative to allow for women to seek care. A retired community member shared an instance where she was the secondary caregiver for her grandchildren and became ill while supervising the children. Although she reached out to her other daughters, they had prior obligations, resulting in her having no choice but to delay her own medical care. Similarly, a primary care physician and mother of two explained, “I am lucky enough to have some support, but when that person is sick it is the same as me being sick, so looking at caretakers it goes the whole way down the line”. These stories further validate the role of childcare responsibilities in delaying women’s access to care, regardless of age and if they are a primary or secondary caregiver.
Theme 5. The need for childcare alternatives in healthcare facilities: The informants suggested that if medical facilities had adequate space and accommodations to watch children, women may be more likely to feel comfortable bringing children with them to their medical visits. The informants discussed that supervising children is always an added concern, but as an employee in the catering industry emphasized, “If you could take the kids with you, it would ease a lot of people’s unnecessary stress”. Many of the participants discussed how this was already provided in fitness centers, for example, as a practical way to address the barrier of childcare. It was proposed that similar systems could be developed to address the childcare barrier in healthcare. None of the informants had heard of any emergency department offering childcare services, and only one participant was aware of a private medical practice offering such services. A university employee shared that she had personally used the services and brought her 2- and 4-year-old children with her to appointments, where they could play in a supervised area while she was seen by the physician. She shared how this service helped to alleviate childcare as a barrier to seeking care. The informants felt that women overall would feel a sense of trust leaving their children at a childcare center in the health care setting, especially because they believed responsible people would be hired for the positions and that the owners of the health care facility would also have more of a liability and legal commitment. However, the informants agreed that educating women about childcare services should involve a large campaign, focusing on reminding women that they have the right to go to the doctor or other health care provider (seek care). As a city high school teacher described, “I don’t care what socioeconomic status you come from, every woman is affected by the issue of childcare or being a caretaker for someone else … until we are educated about knowing that we have to take care of ourselves it won’t have an impact… it needs to become normalized that there is childcare at the doctor’s office or emergency room”.

Discussion

The results of this study’s community needs assessment support those previously identified in the Kaiser Women’s Health Survey, which also found that 13% of women delayed medical care due to lack of childcare responsibilities [1]. However, our study demonstrated that, for women with children under the age of 18 and with multiple children living at home, the percentage is much higher, further highlighting the role of childcare responsibilities as a barrier to women’s health care. This finding is of particular interest because approximately half of all women aged 18 to 64 have children under the age of 18 at home [25].
The SEPA survey results indicate that the more children a woman is caring for, the more likely she is to delay personal health care, not fill a prescription, and not seek dental care due to cost, further validating the association between childcare responsibilities and healthcare practices. The increased expenses and logistical concerns related to an increasing number of children is a real barrier for women increasing their risk for delaying personal health care as financial resources become more limited.
The qualitative component of the study further elaborated on and enhanced understanding of the quantitative findings that childcare responsibilities are associated with women delaying medical care. For example, the costs associated with children and the guilt of using limited resources needed for the children were described in the interviews as contributors to women’s decisions to delay medical care. Cost has been found as a barrier for accessing care for women in other studies, but this research further elaborates on how cost acts as a barrier particularly for women with childcare responsibilities [9]. The economic burdens that many families face influence healthcare practices as resources are limited. According to Columbia University’s National Center for Children in Poverty, in the year 2011 of the more than 72 million children in the United States under the age of 18, 45 percent lived in low-income families, while 22 percent lived in poor families [26]. In regards to health insurance, among all children under 18 years of age, approximately 11 percent in lowincome families and 10 percent in poor families were uninsured [26]. This may further influence women’s decisions to delay their own medical care as they prioritize their children’s healthcare needs. The prioritization of children’s needs was discussed by the key informants for many women regardless of social status but as parents pay out of pocket for child-related health expenses because of a lack of insurance, this burden is undoubtedly worsened. Moreover, among caregivers, nearly 17 million care for special needs children which may only further contribute to the role of childcare as a barrier [27].
As highlighted in Figure 2, most of the key informants (85%) agreed that healthcare providers should discuss childcare responsibilities with women. However, most informants were unaware of many healthcare visits where childcare responsibilities were discussed. The informants recognized the key role of healthcare providers in helping women to identify childcare responsibilities as a barrier in order to better partner with their providers to improve care.
Based on results from the demographic questionnaires completed by key informants, many of whom are formal and informal leaders within their organizations (Figure 3), several other conclusions can be made. First, of the 47 percent of the women reported delaying routine medical care at least once within the past year due to childcare responsibilities, 9 percent of these women delayed care 3-4 times, and 21 percent 5 times or greater. This highlights how delay of care due to childcare responsibilities is often a repeatedly encountered burden, not just a onetime occurrence. More importantly, a few women discussed during the interviews how this delay of routine care as a scheduled outpatient visit eventually led to an emergency room visit. Addressing this childcare barrier can, therefore, potentially decrease emergency room visits by women over time, saving the health care industry money.
In 2010 nearly one in four children lived in households that were classified as food insecure [16]. This further underscores the economic burdens that may be exacerbated as women seek to provide for their children. As the key informants discussed, if women are forced to choose between providing for their children and their own health or wellness needs, they will often sacrifice their own wellbeing to care for their children. Lower income women also tend to have fewer workplace benefits, such as less paid sick leave [1,25]. In fact, it is estimated that more than forty percent of private sector workers in the United States are not granted any paid sick days [28]. This further exacerbates the association between childcare responsibilities and healthcare access. Similarly, racial inequalities may be an important factor, as employed Asian and White women have been shown to be more likely to work in higher paying management, professional, and related occupations, while Black and Hispanic women are more likely to work in service occupations [29]. Further research can be used to highlight unique differences in various racial subgroups of women based on experiences of discrimination and inequality.
Eight in ten of the lowest wage workers lose income and risk job loss when missing time for illnesses [30]. Therefore, as discussed by the informants, because women often serve as the primary caregivers for their children’s health, limited workplace allowances are often reserved for caring for sick children rather than their own health needs. Additionally, as women’s overall time pressure has continued to increase significantly in the past few decades [31], any limited free time, in turn, has become mostly child-centered [32]. This was also discussed by the informants.
Key informants also discussed their perceptions that in some instances the logistics of obtaining care were associated with marital status. However, this perception was not substantiated in the quantitative component. Nevertheless, the potential additional support women may receive from a spouse may not have been completely captured in the specific focus of this assessment of medical care seeking behaviors and childcare responsibilities. Informants did feel that marital status influenced the relationship between delaying medical care and childcare responsibilities. This is challenging as twoparent households continue to decline.
Of note, the community needs assessment found a surprisingly high percentage of women who reported delaying seeking medical care due to childcare responsibilities despite having grown children or no children of their own. This finding underscores the importance of healthcare providers assessing childcare as a barrier for all women because many women, regardless of whether they have children of their own, fulfill the role of a childcare provider through babysitting duties, tending to the children of relatives, or caring for the children of a significant other. In fact, two-thirds of women with children under 18 years of age are employed, with the majority working full time [25]. As a result, their children are taken care of by alternate providers (many of whom are women) while mothers are working. In 2010, nearly half of children ages 0 to 4 with employed mothers were primarily cared for by a relative while the mother worked; a much smaller percentage spent time in a care center or were cared for by a non-relative babysitter [16]. Studies have also shown that women, more so than men, in the caregiver role benefit greatly in terms of decreased stress and more positive health behaviors from counseling and speaking with someone about their caregiving experience [2]. Thus, patient navigators, community health workers or other support persons may be able to help women to address this barrier once it is identified by healthcare providers. For this reason, healthcare providers need not only to improve their overall screening of childcare responsibilities as a barrier to optimal health care and practices but also extend such conversations to all women, not just those who report children.
This study highlights the need to further explore and address the childcare barrier. Currently there is no concerted effort to address this barrier for women’s medical care. Similarly, healthcare providers, who strive to prevent patients from delaying medical care, are not actively addressing the childcare issue and its role as a barrier to medical care for many patients. The results of our study further suggest potential benefit from offering temporary childcare services at emergency departments and large-scale healthcare provider offices, similar to those offered at fitness centers and courthouses nationwide [33,34]. Offering child care services would allow patients to bring their children to the emergency room or medical visits without delaying care in an attempt to find childcare services. It would also eliminate distractions in providing care, as women bringing children into the examination room often results in physicians navigating through noise and interruptions, as well as modifying sensitive health care discussions. However, further research is needed to explore how this can be implemented in the most cost effective manner and in which settings these services would be feasible. Patients would also need to be actively educated about the role of such services, especially in the emergency room setting, and about their individual patient rights. For example, some women may fear leaving their children in childcare services at the emergency room due to negative past experiences with the Department of Human Services (DHS) or similar organizations.
The key informants felt that healthcare providers should address childcare responsibilities as a potential barrier to health care with all women, yet this is not standard practice. The following recommendations of questions to consider as part of the patient history discussion are suggested on the basis of the study findings.
Do you have children of your own or act as a childcare provider in any way?
• If so,
o Have you ever delayed medical care due to childcare responsibilities?
o How can our office feasibly assist in providing an appointment schedule and/or treatment plan most suitable to your needs as a childcare provider?
o Do you have a posted list of emergency contacts and backup childcare providers in place should you become ill and need to seek emergency treatment?
o What role does your childcare responsibilities play in your personal health decisions and goals?
The childcare barrier cannot be overcome until healthcare providers make a conscious effort to begin the conversation and explore potential childcare responsibilities along with making accommodations to address these issues. Moreover, providers or other support staff (patient navigators, community health workers, etc.) can assist patients in the development of emergency action plans and other efforts that can help women address the childcare barrier.

Limitations

There are several limitations to this study. First, a non-randomized sample was used for the community based needs assessment and may be vulnerable to selection bias. In addition, the needs assessment was conducted as a general needs assessment (quantitative component) for women’s health needs and not developed specifically to assess the role of childcare responsibilities in women’s medical care. The community assessment and key informant interviews were also only implemented with women and limited geographically to Philadelphia, Pennsylvania, so making comparisons with men and differences in other geographic locations is not possible. However, as the focus of this project was to identify the role of childcare responsibilities in women’s delay of medical care it was important to better understand this barrier in women solely before addressing this barrier as a possible issue for men. In addition, other variables, such as the length of delay were not captured in the quantitative data.

Conclusions

Childcare responsibilities are a barrier to women’s timely access to preventive, routine and emergent medical care. Healthcare providers and other support persons should discuss childcare responsibilities as a possible barrier to medical care and health practices with all patients, regardless of whether the patients have children of their own. Providers and other support staff should also actively discuss the development and use of emergency action plans for emergency situations as well as other mechanisms and supports available for addressing this barrier in female patients. The first step to overcoming this potential burden is for healthcare providers to begin addressing childcare responsibilities as a barrier to women’s healthcare. By discussing childcare responsibilities with all patients, offering flexible office hours, and exploring the option of providing childcare services, health care providers can begin to help lower the impact of childcare responsibilities on women’s medical care seeking delay. The potential role of childcare responsibilities on men’s health is a topic of future study.

Acknowledgments

We would like to thank the Office on Women’s Health, Grant #1 CCE WH 101015-02-00, Coalition for a Healthier Community Program, for funding this project. We would also like to thank all of the Coalition members, community site partners, key informants and everyone who participated in and contributed to this project.

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