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

1. Access to and Utilization of Health Services by Rural-Dwelling Ohio Children: Are There Unique Challenges for those in the Appalachia Region? Laureen H. Smith, PhD, RN Principal Investigator The Ohio State University June 1, 2009

2. Research Team • Pamela Salsberry, PhD, RN • Co Investigator • Jodi Nearns, PhD, RN • Co Investigator • Christopher Holloman, PhD • Statistician

3. Introduction and Background • Children living in Rural Ohio • Children living in Rural Appalachia • Appalachia Ohio: • Counties that Border the Ohio River • Comparisons to Date • Urban and Rural

4. Purpose of Study 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

5. Specific Aims Are there differences in the health? Are there differences in health care access? Are there differences in health care utilization? What is the relationshipbetween health, health care access and health care utilization? How do Appalachian children living in river-bordering countiescompare to the other children?

6. Geographic Regions of Interest

7. : “Smith’s” Adaptation of Aday’s Framework for Understanding Access and Utilization (Aday et al, 1999)2 Guiding Framework

8. Methods 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

9. Sample • Un-weighted sample • Rural Children: N = 2750 • Appalachia Children: N = 2954 Weighted values were applied to all model variables using Weight_C

10. 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

11. Other Key Controls • Parent Health • Perception of general health D30 • BMI Category BMI_A_CAT

12. Analysis Plan Descriptive Analyses Chi-Square Tests Correlations Bi-variate and Logistic Regression Bayesian Hierarchical Modeling

13. 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

14. Diagram of Hypothesized Model

15. Descriptive & Chi Square Results

18. Health: Key Findings 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

22. Correlations: Health

23. Correlations: Access to Care

24. Correlations: Care Utilization

25. Regression Analysis • Noteworthy findingsChildren 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

26. Modeling Results for Rural Children

27. Modeling Results for Appalachian Children

28. Rural and Appalachian Model Comparisons 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

29. Rural and Appalachian Model Comparisons 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 Governmentinsurance improved access for Appalachian children Rural children with government insurance did not differ from uninsured in accessing care

30. Rural and Appalachian Model Comparions • Morewellness 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

31. Rural and Appalachian Model Comparisons 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

32. Modeling Results for Non-River Appalachian Children

33. Modeling Results for River-Bordering Appalachian Children

34. 3 Group Comparions 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 lessaccess to care (compared to other Appalachia and rural)

35. 3 Group Comparisons Wellness care most prevalent in River-bordering Appalachia Wellness care leastprevalent 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

36. Discussion 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

37. Limitations Used 2008 OHFS data only Measures of child and parent health Locations of care not included Under-insured

38. Policy Implications 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