Laureen H. Smith, PhD, RN Principal Investigator The Ohio State University June 1, 2009

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


Well Baby/Child Checkup

1.0 .019

Preventive Dental Care 1.0Sickness Care

Days since Last Doctor’s Visit

Seen Specialist for Care


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








NumberER visits


gender

ethnicity

Access(aijk)


(wijk)


(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


Private Insurance

Uninsured

Modeling Results for Appalachian Children

LAS14 (Vision Care)

Geography

GovernmentInsurance

Placefor care








NumberER visits


gender

ethnicity

Access(aijk)


(wijk)


(sijk)

ChildHealth(poor)

BMIGeneral

Health Status

Results for Appalachian Children


ParentHealth(poor)

gender

ethnicity

Blue = Male Gender


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








NumberER visits


gender

ethnicity

Access(aijk)


(wijk)


(sijk)

ChildHealth(poor)

BMIGeneral

Health Status

Results for Non- River Bordering Appalachian Children


ParentHealth(poor)

gender

ethnicity

Blue = Male Gender


Private Insurance

Uninsured

Modeling Results for River-Bordering Appalachian Children

Geography

GovernmentInsurance

Placefor care








NumberER visits


gender

ethnicity

Access(aijk)


(wijk)


(sijk)

ChildHealth(poor)

BMIGeneral

Health Status

Results for River–Bordering Appalachian Children


ParentHealth(poor)

gender

ethnicity

Blue = Male Gender


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

Documents

Laureen H. Smith, PhD, RN Principal Investigator The Ohio State University June 1, 2009