Vol.1, No.3, 135-142 (2011)
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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: isabelle.bairati@chuq.qc.ca
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.
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
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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
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.
Sess ion
Speech and
Assessmen t
of Eligible
Entry in the
Home Visit
Satisfactio n
2 weeks2 weeks
Activities of the Study
Activities of the Program
Figure 1. Timeline of activities in the program and in the
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
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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
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)
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.
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 (%)
91 (90.1)
Marital status of the biological parents—n (%)
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
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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-
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
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)
36/47 (76.6)
47/54 (87.0)
Living in a single-unit housing
15/27 (55.6)
60/74 (81.1)
18/27 (66.7)
65/74 (87.8)
Mother employment status
Full time
Other status
38/46 (82.6)
37/55 (67.3)
42/46 (91.3)
41/55 (74.6)
Mother education
Primary or secondary school
Post-secondary school
12/24 (50.0)
63/77 (81.8)
14/24 (58.3)
69/77 (89.6)
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)
1.12 - 1.58
Annual familial income (CDN $)
11/30 (37)
25/45 (56)
Eldest child
21/35 (60)
15/40 (38)
Child with health problems at birtha
33/60 (55)
3/15 (20)
0.03 - 0.82
Mother history of miscarriage
20/51 (39)
16/22 (73)
1.96 - 47.43
Total stress index of the index parentb
29/65 (45)
7/10 (70)
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
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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
32/76 (42)
6/7 (86)
Father employment status
Other status
29/70 (41)
8/10 (80)
1.08 - 31.2
Living in a single-unit housing
12/18 (67)
26/65 (40)
Eldest child
22/40 (55)
16/43 (37)
Only child
31/59 (53)
7/24 (29)
Behavioral problems of the childa
28/69 (41)
6/8 (75)
Parental distress of the index parentb
26/42 (62)
12/41 (29)
0.11 - 0.73
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
47/88 (53)
10/13 (77)
Eldest child
33/50 (66)
24/51 (47)
Child with health problems at birtha
50/80 (63)
7/21 (33)
0.12 - 0.93
Parental distress of the index parentb
35/52 (67)
22/49 (45)
0.19 - 0.98
Dysfunctional interaction between the
index parent and the childb
32/48 (66.7)
25/53 (47.2)
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).
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
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
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
We thank all the SL therapists from the program who invited fami-
lies to participate in the study.
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