Health, Interrupted
Well-child visits are a core component of preventive healthcare in the US. The American Academy of Pediatrics currently recommends ten visits in a child’s first two years and then annually through the end of adolescence.
Yet, as with so many other aspects of daily life in households with young children, the COVID-19 pandemic is disrupting well-child visits. A failure to reverse these trends in coming weeks and months will have serious immediate and long-term negative impacts on the health of both the population and the economy.
The COVID-19 pandemic is disrupting well-child visits.
Media coverage of the pandemic’s impact has already highlighted a 70–80% decline in the volume of all healthcare appointments for infants and children.
More specifically, pediatric well-child visits have decreased substantially since the start of the pandemic, according to surveys of pediatricians and other sources. Relatedly, the Centers for Disease Control and Prevention is reporting significant drops in the number of vaccinations that typically occur during the well-child visits.
We add key facts to existing published information with data from our nationally representative survey of parents and other caregivers with children age 5 and under.
Specifically, our data shed light on the families for whom declines in well-child visits are occurring the most, and also provide insights into why this may be the case.
Our findings make it clear that we must act urgently to address this situation.
What do the overall data show?
27% of all parents and other caregivers of young children in our survey report missing at least one well-child visit in the weeks between April 6 and May 18.
If these trends are not reversed, an increasing proportion of households can be expected to miss one or more scheduled well-child visit in the coming months; moreover, infants and young children, whose visits occur at frequent intervals, are at greatest risk to miss multiple visits as time goes by.
Even at present, rates of missed visits are cause for concern.
Existing pre-pandemic data on well-child visit participation indicate an average 91% of the population was being seen across all well-child visits scheduled for the first 5 years, with some visits (e.g. the newborn visit) approaching near 100% participation.
Our data indicate a threefold decline in well-child visit participation over a relatively brief period.
Why are visits not occurring?
The single biggest reason for missing visits was concerns about being exposed to COVID-19 — endorsed by close to 75% of our survey participants. This was true regardless of income level or racial/ethnic group.
The clear implication of this finding is that the healthcare system, and pediatric primary care in particular, need to increase efforts to mitigate these concerns.
In which subgroups are there more missed visits, and why?
Our data also show that the reduction in well-child visits is higher in some groups than others. Specifically, the percentage of lower-income households missing well-child visits (30%) was significantly higher than the percentage of middle- and upper-income households (23%).
Costs were mentioned as a major barrier to well-child visits in over 40% of low-income households, a number likely to increase as more people lose access to employer-based health insurance.
In addition to income differences, we found racial/ethnic differences. In particular, both African American (33%) and Latinx/Hispanic households (35%) had a significantly higher percent of missed visits than White/Non-Hispanic households (27%). Notably, higher rates of missed well-child visits in households of color existed before the pandemic hit — likely associated with barriers to healthcare access — so this result is a continuation of that trend.
Our data suggest two main reasons why African American and Latinx/Hispanic households are reporting fewer well-child visits. Both groups reported significantly more obstacles in attending these visits in two areas, relative to White/Non-Hispanic households:
Getting time off work: 42% of African American and Latinx/Hispanic households reported difficulty getting time off work as an obstacle to well-child visits, as opposed to 27% for White/Non-Hispanic households. This is noteworthy because it is an obstacle that likely existed prior to the pandemic as well, and further highlights general barriers in access to healthcare experienced by families and households of color.
Providing care for others in the home: 53% of African American and Latinx/Hispanic parents and other caregivers reported a need to provide care for others in their home as an obstacle to well-child visits, as opposed to 31% for White/Non-Hispanic households. This may be a reflection of the extended family structure in many households of color, and the extent to which concerns exist about exposing elderly members of the household to the virus.
Why are missed well-child visits such a great cause for concern?
Well-child visits help build the foundation of children’s current and future health and well-being in a number of ways.
Gathering standard information about height and weight, vision, hearing, and reflexes, can ensure that the child is on a healthy trajectory.
Much concern has been raised about the impact of missed vaccinations that ordinarily occur during well-child visits. For example, as reported in the New York Times, one survey found that between mid-February and early April, measles, mumps and rubella shots decreased by 50 percent, and diphtheria and whooping cough shots decreased by 42 percent. If vaccination levels remain at such low levels, there is a risk of new outbreaks of childhood illnesses long considered to have been virtually eliminated in the US.
Early screening and identification can help to address developmental delays, autism spectrum disorders, genetic syndromes, and other disorders. It has long been recognized that the earlier such issues are recognized, the better the long-term prognosis is for the child.
Finally, well-child visits allow pediatric health care professionals to assess the well-being of the caregiver-child relationship, and to inquire about the mental health of both child and caregiver. This point of contact can help prevent child maltreatment, can identify risk for post-partum depression and domestic violence, and can also promote secure attachment relationships between adult and child. In these times of increased stress and uncertainty, the pediatric health care setting has the potential to strengthen the well-being of households with young children. However, in order for this to occur, well-child visits must resume at pre-pandemic rates.
Recommendations
The following recommendations may be helpful in addressing barriers and increasing rates of participation in well-child visits back to pre-pandemic levels:
Provide funding to support the capacity of healthcare practices to provide outreach related to safety and perceived safety of well-child visits.
Reduce inequalities associated with access, which existed in low income households and households of color prior to the pandemic and continue to exist.
Implement policies that allow time away from work for well-child visits, and that make it possible to obtain reliable and affordable sources of care for other family members to make such visits possible may increase access.
Address concerns about the cost of well-child visits by ensuring insurance coverage for all households with young children.
Suggestions for further reading
Our team has curated a selection of important background readings for anyone interested in further exploring the effects of the pandemic on well-child visits and the broader implications of those trends.
“AAP issues guidance to ensure continued care for children during pandemic,” American Academy of Pediatrics.
“Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration—United States, 2020,” Centers for Disease Control and Prevention.
“Vaccine Rates Drop Dangerously as Parents Avoid Doctor’s Visits,” New York Times.
“What Parents Need to Know About Well-Child Visits During Coronavirus,” Huffington Post.
“The Impact of COVID-19 on Infant and Child Health Care, Beyond Missed Vaccinations,” ABC News.
About the project
When the COVID-19 pandemic emerged last winter, there were over 24 million children age five and under living in the United States. This period of early childhood is a critical window that sets the stage for health and well-being across the lifespan. As such, it is essential during the current health and economic crisis to listen to the voices of households with young children.
The weekly survey of households with children age five and under launched on April 6, 2020. Since then, we have been gathering weekly data about child and adult emotional well-being, financial and work circumstances, availability of healthcare, and access to child care/early childhood education.
We will continue to report on these issues as we learn more from each new weekly survey. We will also be producing policy briefs that make concrete recommendations about how to address the challenges we are seeing emerge from the family surveys.
Our goal is to use what we are hearing from families to improve the well-being of all households with young children, during the pandemic and beyond.