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A Possible Reason for Failure to Access Community Services?

M FAMILIES REFERRED to community-based programs and services never receive them. Our own experience with a city-wide program in Hartford, Connecticut, supports this observation. ChildServ, implemented in 1998, was designed to improve the early detection of children at risk and promote their (and their families’) linkage to community-based services and supports. Only 43% of referred children ultimately received services despite an average of 6.9 contacts with the family after initial referral.1 We did not understand why linkage rates were not higher, particularly because the families were preferentially referred to neighborhood programs that were in close geographic proximity and considered culturally “appropriate.” In this issue of Pediatrics Electronic Pages, Silverstein et al2 propose a potentially important explanation for such observations. Analyses of interviews comprising predominately open-ended questions to 41 urban, low-income mothers in Seattle, Washington, and Boston, Massachusetts, suggest specific themes that reflect negative perceptions of using community resources. Such themes include the imposition of external requirements, structure, and value systems; the perceived loss of control over one’s life circumstances; the unhelpful, formulaic nature of recommendations; and staff being regarded as judgmental, intrusive, or overbearing. The authors speculate that such perceived disadvantages to engaging with community resources may create additional barriers to engagement and suggest the potential benefit of improving the client centeredness of organizations to reduce such barriers. In addition to implications for care coordination, this study affords readers who are unfamiliar with qualitative research a primer on this methodology and its potential to yield unexpected, but important, findings. The authors describe the use of open-ended questions, ethnographic-style qualitative interviewing, a groundedtheory approach to data analysis, and corroboration of findings through the techniques of investigator and expert triangulation and member checking. Clear explanations and cogent examples overcome the risk of alienating readers by the use of unfamiliar jargon, thereby offering a hypothesis-generating approach to complement more-traditional quantitative, hypothesis-affirming methodologies. The recently published third edition of Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents3 by the American Academy of Pediatrics emphasized the role of the child health provider in linking children and their families to community-based programs and services. Promoting access to community resources is also embedded within the concept of the medical home, programs of early detection and intervention for children with special health care needs, and principles of the chronic care model and patient-centered (and family-centered) care.4–6 Failure to consider parents’ perceptions of community resources may undermine the best of intentions and recommendations. The extent to which parents’ beliefs and perceptions are the consequence of interactions with community programs is, of course, speculative. The authors acknowledge the importance of context and of viewing life as a series of compromises. Perhaps contextual issues (eg, poverty, food/housing insecurity, racism) promote the perceptions that create barriers to accessing community services. Nonetheless, findings remind us of the critical importance of listening to families, soliciting their opinions and concerns, and engaging them as partners in care. Findings also suggest that our considerations of patientand family-centered care should extend from the bedside to the office and to the community.