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Laureen H. Smith, PhD, RNPrincipal Investigator
The Ohio State UniversityJune 1, 2009
Pamela Salsberry, PhD, RN• Co Investigator
Jodi Nearns, PhD, RN• Co Investigator
Christopher Holloman, PhD• Statistician
Children living in Rural Ohio
Children living in Rural Appalachia
Appalachia Ohio:• Counties that Border the Ohio River
Comparisons to Date Urban and Rural
Examine if there are differences in access to and utilization of health care services between children living in rural areas and children living in Appalachian areas of Ohio
Describe the underlying health of these children
Are there differences in the health?
Are there differences in health care access?
Are there differences in health care utilization?
What is the relationship between health, health care access and health care utilization?
How do Appalachian children living in river-bordering counties compare to the other children?
ENVIRONMENTPhysicalSocial
Economic
Health Policy Federal, State, Local
DELIVERY SYSTEMAvailabilityOrganizationFinancing
POPULATION AT RISKPredisposingEnablingNeed
REALIZEDACCESSUtilization
STRUCTURE
PROCESS
: “Smith’s” Adaptation of Aday’s Framework for Understanding Access and Utilization (Aday et al, 1999)2
Data from 2008 OFHS
Child Questionnaire and Parent Health Status Data
Children – someone under the age of 18 years
Parent – mother or father of said child
Un-weighted sample• Rural Children: N = 2750• Appalachia Children: N = 2954
Weighted values were applied to all model variables using Weight_C
Table 2: Measures
Framework Construct/Variables Measure OFHS Data ElementSTRUCTURE
Delivery system availability Access
Regular place of care Yes/No N137, N137 CheckRegular provider Yes/No N137b
Difficulty accessing specialty care No or small problem/Big problem K4Q26
Populations-at-risk
Age in years, Race/ethnicity (white, Black, Asian, Native American, Hispanic)
Age_c; race_c_impi90,P150,P148
Predisposing Age, ethnicity, gender
Enabling Health Insurance Private, Gov’t, Uninsured J100a-J100f; J120, H87Need Health
Parent-reported health status; Weight state (under weight, normal weight, overweight, obese)
L125, BMI_C, BMI_c_CAT
Environments
Physical, social, economic Geographical Region Appalachian County_ARiver, Non-RiverRural, non-AppalachianPROCESS
Realized Access UtilizationWell Care Well child/baby visit M130
Preventive Dental Care M130aSick Care ER visits; # days since non-preventive
dental visits; Overnight hospital; Seen by specialist; # days since last MD visit
K4Q24;M132;M135;M134;M131
Note: N137 (regular place for care) was recoded in such as way that it is the same as the created variable “usual_c” found in the final OFHS dataset
Parent Health• Perception of general health D30• BMI Category BMI_A_CAT
Descriptive Analyses
Chi-Square Tests
Correlations
Bi-variate and Logistic Regression
Bayesian Hierarchical Modeling
Cross-sectional data with reasonable latent factors
Not assuming a linear relationship with all variables
Not constrained to assume linear relationships
Not constrained to assume normal distribution
Models for missing data
Directly test the interactions between groups
LAS14 (Vision Care)
GovernmentInsurance Coverage
PrivateInsurance Coverage
Placefor care
Health Care Provider
DifficultyAccessing Specialist
Seen by aSpecialist (for care)
Well childor babycheckup
Preventive Dental Care
Days Lastdoctor visit
NumberER visits
BMI GeneralHealthStatus
gender
ethnicity
Access(aijk)
Well Care Utilization
(wijk)
Sick Care Utilization
(sijk)
ChildHealth(poor)
BMI General Health Status
ParentHealth(poor)
gender
ethnicity
Overnight Hospital Stays
Days LastNon-preventive Dental visit
Demographics Rural AppalachiaChildAgeMeanSD
9.135.16
9.125.23
Gender (%)MaleFemale
51.148.9
49.650.4
Ethnicity (%)WhiteBlackAsianNative AmericanHispanic
93.62.60.70.21.3
95.42.00.50.50.8
Parent/GuardianGender (%)MaleFemale
32.767.3
30.969.1
Ethnicity (%)WhiteBlackAsianNative AmericanHispanic
94.1 2.0 0.9 0.9 1.6
94.5 2.2 0.4 1.1 1.1
Unemployed (%)(Neither Parent Employed)
9.3 14.4
Child Health Rural Appalachia
Perceived General Health (%)ExcellentVery GoodGoodFairPoorDon’t Know/Refused
54.828.213.4 3.2 0.2 0.2
56.527.612.4 3.2 0.2 0.1
Body Mass Index (%)UnderweightNormal weightOverweightObeseOut of Range
2.759.218.219.7 0.1
4.857.115.722.4 0.0
Parent Health
Perceived General Health (%)ExcellentVery GoodGoodFairPoor
20.036.129.410.4 4.0
15.934.229.115.5 5.2
Body Mass Index (%)UnderweightNormal WeightOverweightObese
1.632.834.830.9
2.133.733.330.9
No difference between Appalachian and Rural Children
Children who are underweight, overweight or obese had poorer general health
Male children had poorer health
Black and Hispanic children had poorer health
Parent health was related to child health
Black and Hispanic parents has poorer health
Rural Appalachia
Provider Access
Has Personal Doctor or Nurse(%) YES(%) NO
91.5 8.3
90.1 9.7
Access to a Place for Care
Child has a place for care(%) YES(%) NODon’t Know/Refused
96.7 3.1 0.2
97.3 2.3 0.5
Difficulty with Access SpecialistIf Seen by Specialist, Perceived Difficulty (% for those who saw a specialist)No problem or Small problemLarge Problem or Much Difficulty
91.67.8
92.76.3
Type of Insurance Rural Appalachia
(%) on Government
31.5 46.1
(%) on Private 58.3 43.3
(%) Insured – type unknown
5.3 5.8
(%) Uninsured 4.9 4.8
(%) Medicaid Eligible-not enrolled d
10.5 12.0
Type of Utilization Rural AppalachiaWellness CareReceived well baby or well child checkup (within past year)%YES%NO
68.930.0
73.425.4
Dental Visit for Standard Check Up(within past year)(%) YES(%) NO
72.027.5
73.026.0
Sickness CareHas seen a Specialist for Care(%) YES(%) NO
24.674.9
23.076.6
Average Number of Overnight Hospital Stays (within past year)- total sampleStandard Deviation% of Total that were Users
1.57 .15 7.0
1.61 .175.5
Average Number of ER visits (within past year) –total sampleStandard Deviation% of Total that were Users
1.79 .1521.9
1.79 .1621.8
Health
Parent Health Status
Child Health Status
Parent BMI
Child BMI
Parent Health Status
1.0 .318 .226 .122
Child HealthStatus
1.0 .052 .183
Parent BMI 1.0 .202
Child BMI 1.0
Access to Care
Regular Provider
Regular Place
Difficulty with Specialist Care
Regular Provider
1.0 .356 -.087
Regular Place 1.0 -.099
Difficulty with Specialist Care
1.0
Wellness Care
Well Baby/Child Checkup
Preventive Dental Care
Well Baby/Child Checkup
1.0 .019
Preventive Dental Care 1.0Sickness Care
Days since Last Doctor’s Visit
Seen Specialist for Care
Overnight Hospital Stays
ER Visits
Days since Last Doctor’s Visit
1.0 -.192 .127 -.151
Seen Specialist 1.0 .167 .190Overnight Hospital Stays
1.0 .243
ER Visits 1.0
Noteworthy findings Children who had a regular place for care were 3 ½ times more likely to have had a well
baby/child check up
• Children who had a regular provider were 1 ½ times more likely to have had a well baby/child check up
• Children in poorer health were less likely to have had a well baby/child check up
• Children with a regular provider were 1 ½ times more likely to have receive preventive dental care
• Children with a regular place for care were 2 ½ times more likely to receive preventive dental care
Modeling Results for Rural Children
LAS14 (Vision Care)
Geography
GovernmentInsurance
Placefor care
Health Care Provider
DifficultyAccessing Specialist
Seen by aSpecialist (for care)
Well childor babycheckup
Preventive Dental Care
Overnight Hospital Stays
Days Lastdoctor visit
NumberER visits
BMI GeneralHealthStatus
gender
ethnicity
Access(aijk)
Well Care Utilization
(wijk)
Sick Care Utilization
(sijk)
ChildHealth(poor)
BMIGeneral
Health Status
Results for Rural Children
Green = Significant results in positive direction / Red = Significant results in negative direction / Black = not significant------- = slope parameter restricted to 1
ParentHealth(poor)
gender
ethnicity
Blue = Male Gender
Days LastNon-preventive Dental visit
Private Insurance
Uninsured
Modeling Results for Appalachian Children
LAS14 (Vision Care)
Geography
GovernmentInsurance
Placefor care
Health Care Provider
DifficultyAccessing Specialist
Seen by aSpecialist (for care)
Well childor babycheckup
Preventive Dental Care
Overnight Hospital Stays
Days Lastdoctor visit
NumberER visits
BMI GeneralHealthStatus
gender
ethnicity
Access(aijk)
Well Care Utilization
(wijk)
Sick Care Utilization
(sijk)
ChildHealth(poor)
BMIGeneral
Health Status
Results for Appalachian Children
Green = Significant results in positive direction / Red = Significant results in negative direction / Black = not significant------- = slope parameter restricted to 1
ParentHealth(poor)
gender
ethnicity
Blue = Male Gender
Days LastNon-preventive Dental visit
Private Insurance
Uninsured
Appalachian Children have less access to care
Appalachian Children in poorer health had less access to care
Having a regular care provider improved access to care for both groups
Children with private insurance had better access and care utilization (compared to uninsured)
Insurance coverage had a larger impact on access to care for Appalachian children
Government insurance improved access for Appalachian children
Rural children with government insurance did not differ from uninsured in accessing care
More wellness and sickness care utilization in Appalachia• Regardless of access, health or insurance status
Private insurance most important for wellness care in rural region
Government insurance larger impact on wellness care in Appalachia
In rural region, children in poorer health had less wellness care utilization
In rural region, children with government insurance had more sickness care utilization (compared to uninsured)
Appalachian children with government insurance did not differ from uninsured in sickness care utilization
Having insurance coverage was more important for Appalachian children in sickness are utilization, compared to rural region
Modeling Results for Non-River Appalachian Children
Geography
GovernmentInsurance
Placefor care
Health Care Provider
DifficultyAccessing Specialist
Seen by aSpecialist (for care)
Well childor babycheckup
Preventive Dental Care
Overnight Hospital Stays
Days Lastdoctor visit
NumberER visits
BMI GeneralHealthStatus
gender
ethnicity
Access(aijk)
Well Care Utilization
(wijk)
Sick Care Utilization
(sijk)
ChildHealth(poor)
BMIGeneral
Health Status
Results for Non- River Bordering Appalachian Children
Green = Significant results in positive direction / Red = Significant results in negative direction / Black = not significant------- = slope parameter restricted to 1
ParentHealth(poor)
gender
ethnicity
Blue = Male Gender
Days LastNon-preventive Dental visit
Private Insurance
Uninsured
Modeling Results for River-Bordering Appalachian Children
Geography
GovernmentInsurance
Placefor care
Health Care Provider
DifficultyAccessing Specialist
Seen by aSpecialist (for care)
Well childor babycheckup
Preventive Dental Care
Overnight Hospital Stays
Days Lastdoctor visit
NumberER visits
BMI GeneralHealthStatus
gender
ethnicity
Access(aijk)
Well Care Utilization
(wijk)
Sick Care Utilization
(sijk)
ChildHealth(poor)
BMIGeneral
Health Status
Results for River–Bordering Appalachian Children
Green = Significant results in positive direction / Red = Significant results in negative direction / Black = not significant------- = slope parameter restricted to 1
ParentHealth(poor)
gender
ethnicity
Blue = Male Gender
Days LastNon-preventive Dental visit
Private Insurance
Uninsured
Less overall access to care in River-bordering Appalachian counties
Having private insurance was most important to accessing care in River-bordering Appalachia
In non-River Appalachia, children in poorer health had less access to care (compared to other Appalachia and rural)
Wellness care most prevalent in River-bordering Appalachia
Wellness care least prevalent in Rural region
Sickness care most prevalent in non-River Appalachia
Importance of insurance coverage on sickness care greatest in Rural region
In non-River Appalachia, children with private insurance had less sickness care
Health Professional Shortage Areas
Unique Characteristics of Appalachia
Insurance Status and Access to Care
Insurance Status and Health Care Utilization
Prevalence of Childhood Overweight and Obesity
Used 2008 OHFS data only
Measures of child and parent health
Locations of care not included
Under-insured
Wrap-around services
Expansion of services
Pediatric health care providers
Reduction of “missed opportunities”
Safety net of providers- rural region
Recognizing rural region as vulnerable
Alternative health care delivery methods
BMI Screening & Surveillance
Social Marketing & Education
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