Access to and Utilization of Health Services by Rural-Dwelling Ohio Children: Are There Unique Challenges for those in t

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 Children living in Rural Ohio Lower income Generally areas that lack health care providers & services Barriers to care: distance, travel, Nature of work (small business, agriculture) may impact insurance and underinsurance Rural Appalachia Share some of the same challenges as rural Ohio: lack of providers Shaped by unique regional culture- isolated, prefer to “take care of own” Reduced educational opportunities High unemployment leading to… Economic instability and persistent poverty Rapid increase in childhood obesity Counties bordering OR Disproportionate exposure to environmental conditions R/T coal mining, manufacturing and power generation plants>> pollution 7 OR counties largest chemical releases in the state 40% of state-wide chemical releases occur in this region HIGH incidence of Cancers & cancer deaths Comparisons to Date Rural to Urban children/adolescents Culturally defined areas within these regions has not been included in studies Access to AND utilization of health care services may provide one avenue to improving the life chances of these children Children living in Rural Ohio Lower income Generally areas that lack health care providers & services Barriers to care: distance, travel, Nature of work (small business, agriculture) may impact insurance and underinsurance Rural Appalachia Share some of the same challenges as rural Ohio: lack of providers Shaped by unique regional culture- isolated, prefer to “take care of own” Reduced educational opportunities High unemployment leading to… Economic instability and persistent poverty Rapid increase in childhood obesity Counties bordering OR Disproportionate exposure to environmental conditions R/T coal mining, manufacturing and power generation plants>> pollution 7 OR counties largest chemical releases in the state 40% of state-wide chemical releases occur in this region HIGH incidence of Cancers & cancer deaths Comparisons to Date Rural to Urban children/adolescents Culturally defined areas within these regions has not been included in studies Access to AND utilization of health care services may provide one avenue to improving the life chances of these children

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 Overall goal Because health problems influences health services use, we also describe the underlying health of these children By understanding access and use patterns against the backdrop of overall health, recommendations for structuring services can be madeOverall goal Because health problems influences health services use, we also describe the underlying health of these children By understanding access and use patterns against the backdrop of overall health, recommendations for structuring services can be made

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 relationship between health, health care access and health care utilization? How do Appalachian children living in river-bordering counties compare to the other children? Comparing rural children to Appalachian childrenComparing rural children to Appalachian children

6. Geographic Regions of Interest 29 designated Appalachian counties 30 rural counties Notable differences Household income is lower in Appalachia with 16.55% living below poverty line Rural households – 10.4% live below poverty line Poverty rates have increased in both groups (OFHS) MORE PEDIATRIC HEALTH CARE PROVIDERS IN RURAL OHIO NUMBER OF COUNTIES WITHOUT A PEDIATRIC HEALTH CARE PROVIDER IS GREATER IN APPALACHIA (14/29 COUNTIES OR 48%) 42% OF RURAL COUNTIES LACK A PEDIATRIC HEALTH CARE PROVIDER (13/20 COUNTIES) Based on these structural or system differences, we expect that there will be differences in access and utilization across these regions. Due to greater poverty in Appalachia- expect more of these children to qualify for Medicaid. Ohio is comprised of Appalachian and non-Appalachian regions which uniquely positions it to make these comparisons. 29 designated Appalachian counties 30 rural counties Notable differences Household income is lower in Appalachia with 16.55% living below poverty line Rural households – 10.4% live below poverty line Poverty rates have increased in both groups (OFHS) MORE PEDIATRIC HEALTH CARE PROVIDERS IN RURAL OHIO NUMBER OF COUNTIES WITHOUT A PEDIATRIC HEALTH CARE PROVIDER IS GREATER IN APPALACHIA (14/29 COUNTIES OR 48%) 42% OF RURAL COUNTIES LACK A PEDIATRIC HEALTH CARE PROVIDER (13/20 COUNTIES) Based on these structural or system differences, we expect that there will be differences in access and utilization across these regions. Due to greater poverty in Appalachia- expect more of these children to qualify for Medicaid. Ohio is comprised of Appalachian and non-Appalachian regions which uniquely positions it to make these comparisons.

7. Guiding Framework Guiding framework is Anderson & Aday’s Framework for Understanding Access, Utilization and Health States- adapted for this study. Model Access and use of services is a complex interplay of availability, individual need, individual resources and underlying proclivity to use services. This study – focuses on assessing structure (delivery system, population at risk, environment) and process (realized access)Guiding framework is Anderson & Aday’s Framework for Understanding Access, Utilization and Health States- adapted for this study. Model Access and use of services is a complex interplay of availability, individual need, individual resources and underlying proclivity to use services. This study – focuses on assessing structure (delivery system, population at risk, environment) and process (realized access)

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. Variables used in this study with links to the guiding framework, OFHS data element and level of Measure (structure or process) 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 Variables used in this study with links to the guiding framework, OFHS data element and level of Measure (structure or process) 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 Weighted values were applied using Wt_C variable provided in the database for descriptive, chi square correlations and regression analysesWeighted values were applied using Wt_C variable provided in the database for descriptive, chi square correlations and regression analyses

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

16. Children in both regions are demographically similar Most are Caucasian Average age was similar Most surveys were completed by the child’s mother Parent unemployment is significantly higher in Appalachia, particularly the river-bordering counties (15.6%). General unemployment rate in Appalachia was 6.2% in 2006 and 2007. (reported by ODJFS). Chi Square for this slide = 37.5, p =.000 When doing a 3 group comparison, River Appalachia had the highest rate of unemployment (15.6%) followed by other Appalachia (12.8%). These differences were statistically significant (Chi Square = 40.83, p = .000)Children in both regions are demographically similar Most are Caucasian Average age was similar Most surveys were completed by the child’s mother Parent unemployment is significantly higher in Appalachia, particularly the river-bordering counties (15.6%). General unemployment rate in Appalachia was 6.2% in 2006 and 2007. (reported by ODJFS). Chi Square for this slide = 37.5, p =.000 When doing a 3 group comparison, River Appalachia had the highest rate of unemployment (15.6%) followed by other Appalachia (12.8%). These differences were statistically significant (Chi Square = 40.83, p = .000)

17. Child Health: Majority of parents perceive their child’s health as good-excellent Rural- 38% are overweight or obese Appalachia – 38% are overweight or obese Within Appalachia: Non River – 34.5% are overweight or obese and over 5% are underweight River – 41.4% are overweight or obese and 4.5% are underweight Parents- Significant Differences in general health with rural parents having better general health, compared to Appalachia Parents Chi- Sq = 34.3, p = .000 Approximately 65% of parents are overweight or obese (similar to national trends for adults)Child Health: Majority of parents perceive their child’s health as good-excellent Rural- 38% are overweight or obese Appalachia – 38% are overweight or obese Within Appalachia: Non River – 34.5% are overweight or obese and over 5% are underweight River – 41.4% are overweight or obese and 4.5% are underweight Parents- Significant Differences in general health with rural parents having better general health, compared to Appalachia Parents Chi- Sq = 34.3, p = .000 Approximately 65% of parents are overweight or obese (similar to national trends for adults)

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 Males – 61% of children classified as Obese and 57% of children classified as overweight were males. Ethnic differences Rate of obesity: Caucasian = 19% Black = 28% Parent health : < 25% think their health is excellent Appalachian parents reported highest rates of poor health Underweight, overweight and obese parents reported the hightest rates of poor health Males – 61% of children classified as Obese and 57% of children classified as overweight were males. Ethnic differences Rate of obesity: Caucasian = 19% Black = 28% Parent health : < 25% think their health is excellent Appalachian parents reported highest rates of poor health Underweight, overweight and obese parents reported the hightest rates of poor health

19. Access to care is not uniform between Appalachian and rural children In comparing river and non-river Appalachia, nearly 12% of children living in the river bordering counties lack a personal care provider (88.2%). 95.5% of children living in non-river Appalachian counties had a regular care provider (exceeding rural areas). Over 12% of river bordering Appalachian counties lack a regular health care provider Parents of rural children report the most difficulty in accessing specialty care, followed by River-Appalachia (6.9%)Access to care is not uniform between Appalachian and rural children In comparing river and non-river Appalachia, nearly 12% of children living in the river bordering counties lack a personal care provider (88.2%). 95.5% of children living in non-river Appalachian counties had a regular care provider (exceeding rural areas). Over 12% of river bordering Appalachian counties lack a regular health care provider Parents of rural children report the most difficulty in accessing specialty care, followed by River-Appalachia (6.9%)

20. Over 45% of Appalachian children are on Medicaid, compared to only 31% of Rural children Approximately 99% of children enrolled on government plans are enrolled in Medicaid The non-river counties of Appalachia had the highest rate of governmental based insurance coverage = 47% and Medicaid eligibility but not enrolled (13.1%) In Appalachia, more children are covered by Medicaid than private plans Nearly 5% of rural and Appalachia children are uninsured 12% of Appalachia children are eligible for Medicaid but not enrolled Within Appalachia: Highest rate of government plans and lowest rate of private insurance in the non-river counties Highest rate of Medicaid eligibility (not enrolled) in non-river Appalachia (13.1%)Over 45% of Appalachian children are on Medicaid, compared to only 31% of Rural children Approximately 99% of children enrolled on government plans are enrolled in Medicaid The non-river counties of Appalachia had the highest rate of governmental based insurance coverage = 47% and Medicaid eligibility but not enrolled (13.1%) In Appalachia, more children are covered by Medicaid than private plans Nearly 5% of rural and Appalachia children are uninsured 12% of Appalachia children are eligible for Medicaid but not enrolled Within Appalachia: Highest rate of government plans and lowest rate of private insurance in the non-river counties Highest rate of Medicaid eligibility (not enrolled) in non-river Appalachia (13.1%)

21. Chi Square = 6.3, p = .01 Fewer rural children receive wellness (preventive care) Less than 10% of children were hospitalized however approximately 22%used the ER for care (within past year) Nearly ¼ of children were seen by a specialist for care (type of specialty care not determined) – usual sources include: asthma, ENT, vision according toe Appalachian Rural Health Institute. Fewer rural children receive wellness care Approximately 22% of children visited the ER within the past year Nearly 25% were seen by a specialist for care Within Appalachia: River Appalachia: highest percentage receiving a well baby check up (nearly 76%) Chi Square = 6.3, p = .01 Fewer rural children receive wellness (preventive care) Less than 10% of children were hospitalized however approximately 22%used the ER for care (within past year) Nearly ¼ of children were seen by a specialist for care (type of specialty care not determined) – usual sources include: asthma, ENT, vision according toe Appalachian Rural Health Institute. Fewer rural children receive wellness care Approximately 22% of children visited the ER within the past year Nearly 25% were seen by a specialist for care Within Appalachia: River Appalachia: highest percentage receiving a well baby check up (nearly 76%)

22. Correlations: Health First step in preparing for model analysis was to perform correlations between the indicators for each model factor. First step in preparing for model analysis was to perform correlations between the indicators for each model factor.

23. Correlations: Access to Care

24. Correlations: Care Utilization Well baby/child check up and dental care were not correlated – we analyzed them separately in the model. Well baby/child check up and dental care were not correlated – we analyzed them separately in the model.

25. Regression Analysis 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 To test proposed paths on models: linear, non-linear and logistic regression analysis were conducted between the indicators of each factor. Results suggest support for the proposed model and proposed paths. To test proposed paths on models: linear, non-linear and logistic regression analysis were conducted between the indicators of each factor. Results suggest support for the proposed model and proposed paths.

26. Parent health was positively related to child health (parents in poorer health had children in poorer health) Child health was not related to access to care Children with more access to care received more wellness and sickness care Children in poorer health received less wellness care but more sickness care Private insurance improved both access and wellness care but not sickness care Government insurance improved wellness care and sickness care but not access to careParent health was positively related to child health (parents in poorer health had children in poorer health) Child health was not related to access to care Children with more access to care received more wellness and sickness care Children in poorer health received less wellness care but more sickness care Private insurance improved both access and wellness care but not sickness care Government insurance improved wellness care and sickness care but not access to care

27. Compared to Rural Children Appalachian children have Less General Access to Care, Greater Wellness and Sickness Care Utilization Bolder lines leading from Insurance type indicates that this type of insurance is more important for Appalachian children compared to rural children As opposed to rural children, Appalachian children’s health was not related to their use of wellness care and government insurance was not related to sickness care As opposed to rural children, government insurance did improve access to care (was ns in rural)Compared to Rural Children Appalachian children have Less General Access to Care, Greater Wellness and Sickness Care Utilization Bolder lines leading from Insurance type indicates that this type of insurance is more important for Appalachian children compared to rural children As opposed to rural children, Appalachian children’s health was not related to their use of wellness care and government insurance was not related to sickness care As opposed to rural children, government insurance did improve access to care (was ns in rural)

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 Government insurance improved access for Appalachian children Rural children with government insurance did not differ from uninsured in accessing care

30. Rural and Appalachian Model Comparions 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

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. In Non-River Appalachian Counties: Children in Poorer Health had less access to care, in River Appalachia children in poorer health did not differ from healthier children regarding access The most sickness care utilization occurred in non-river Appalachia, compared to both rural and River Appalachia (regardless of health access, or insurance status) Only having PRIVATE insurance was associated with LESS Sickness Care in this region (compared to uninsured)In Non-River Appalachian Counties: Children in Poorer Health had less access to care, in River Appalachia children in poorer health did not differ from healthier children regarding access The most sickness care utilization occurred in non-river Appalachia, compared to both rural and River Appalachia (regardless of health access, or insurance status) Only having PRIVATE insurance was associated with LESS Sickness Care in this region (compared to uninsured)

33. River Counties Less overall Access to care, compared to rural and other Appalachia Impact of having PRIVATE insurance for accessing care was greatest in this region (most important in this region) Wellness care was most prevalent( regardless of health or insurance status) Children with insurance did not differ from uninsured in the use of sickness care servicesRiver Counties Less overall Access to care, compared to rural and other Appalachia Impact of having PRIVATE insurance for accessing care was greatest in this region (most important in this region) Wellness care was most prevalent( regardless of health or insurance status) Children with insurance did not differ from uninsured in the use of sickness care services

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 less access to care (compared to other Appalachia and rural)

35. 3 Group Comparisons 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

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 31 of Ohio’s rural and Appalachian counties are full or partial geographic, health professional shortage areas. 21 of these HPSAs are found in Appalachian counties that border the Ohio River. More are found in other Appalachian areas serving special populations or geographic areas. Despite these HSPAs, our study found that children living in Appalachia have less access to care., specifically a regular care provider and place for care. Possible Explanations: a) cultural reliance on self and mistrust of others, b) turnover or attrition of providers in HSPAs may be higher than other facilities impacting the perception that a provider is a “regular” care provider Access is closely R/T insurance coverage. Many studies use insurance status as a measure of access. About 5% or 11,000 of Ohio’s children remain uninsured. Lack of insurance generally means a lack of preventive care. 10-13% of children were eligible for Medicaid but not enrolled- reasons are not known: lack of awareness, time constraints, enrollment process, confusion about insurance options, or lack of trust in the health care system (including formal insurance) The TYPE of insurance seems to matter. In rural children only private insurance improved access/ Appalachia – private and government insurance improved access (over uninsured) and the impact of private insurance on access was greatest in Appalachia. More Appalachian children are enrolled in Medicaid (45% verses 31%). Providers in Appalachia may be more willing to accept Medicaid than in rural areas. Uninsured Ohioans are 2x as likely to lack a health provider than insured Ohioans. – thus they rely on ERs for much of their care. Appalachian children use wellness and sickness care services more than rural children. The clustering of HSPAs in Appalachia may be a partial explanation for this finding. Another explanation may be that the safety net providers and services that historically targeted the Appalachian region and continue to cluster in this area. Our findings suggest that rural areas are vulnerable but may not be readily recognized as such. Rural areas may lack the infrastructure and safety net of providers need to ensure health care utilization. Children in poorer health were less likely to have a well/baby check up. Perhaps parents who are visiting a provider frequently for sickness care believe their child is being seen by a “provider” and do not see the reason for any other visits. However, when visiting a provider for sickness care, children may be less likely to be offered: immunizations, physical exams, counseling for growth and development or anticipatory guidance. Most parents perceive their children in good or excellent health but BMI percentiles would indicate otherwise. Nearly 40% of children were classified as overweight or obese. Children who are obese by age 10 years have an 80% chance of becoming an Obese Adult. Without intensive intervention at both the policy and community level, thousands of Ohio’s rural and Appalachian children are destined to become Obese Adults. Obese children run the highest risk of co-morbidities while still in childhood, possibly impacting life expectancy and quality of life. Our findings indicate that childhood under-nutrition is a concern in Appalachia especially in non-river counties where 5% of children are underweight. The national average is only 2%. Persistent poverty is probably the explaining factor 31 of Ohio’s rural and Appalachian counties are full or partial geographic, health professional shortage areas. 21 of these HPSAs are found in Appalachian counties that border the Ohio River. More are found in other Appalachian areas serving special populations or geographic areas. Despite these HSPAs, our study found that children living in Appalachia have less access to care., specifically a regular care provider and place for care. Possible Explanations: a) cultural reliance on self and mistrust of others, b) turnover or attrition of providers in HSPAs may be higher than other facilities impacting the perception that a provider is a “regular” care provider Access is closely R/T insurance coverage. Many studies use insurance status as a measure of access. About 5% or 11,000 of Ohio’s children remain uninsured. Lack of insurance generally means a lack of preventive care. 10-13% of children were eligible for Medicaid but not enrolled- reasons are not known: lack of awareness, time constraints, enrollment process, confusion about insurance options, or lack of trust in the health care system (including formal insurance) The TYPE of insurance seems to matter. In rural children only private insurance improved access/ Appalachia – private and government insurance improved access (over uninsured) and the impact of private insurance on access was greatest in Appalachia. More Appalachian children are enrolled in Medicaid (45% verses 31%). Providers in Appalachia may be more willing to accept Medicaid than in rural areas. Uninsured Ohioans are 2x as likely to lack a health provider than insured Ohioans. – thus they rely on ERs for much of their care. Appalachian children use wellness and sickness care services more than rural children. The clustering of HSPAs in Appalachia may be a partial explanation for this finding. Another explanation may be that the safety net providers and services that historically targeted the Appalachian region and continue to cluster in this area. Our findings suggest that rural areas are vulnerable but may not be readily recognized as such. Rural areas may lack the infrastructure and safety net of providers need to ensure health care utilization. Children in poorer health were less likely to have a well/baby check up. Perhaps parents who are visiting a provider frequently for sickness care believe their child is being seen by a “provider” and do not see the reason for any other visits. However, when visiting a provider for sickness care, children may be less likely to be offered: immunizations, physical exams, counseling for growth and development or anticipatory guidance. Most parents perceive their children in good or excellent health but BMI percentiles would indicate otherwise. Nearly 40% of children were classified as overweight or obese. Children who are obese by age 10 years have an 80% chance of becoming an Obese Adult. Without intensive intervention at both the policy and community level, thousands of Ohio’s rural and Appalachian children are destined to become Obese Adults. Obese children run the highest risk of co-morbidities while still in childhood, possibly impacting life expectancy and quality of life. Our findings indicate that childhood under-nutrition is a concern in Appalachia especially in non-river counties where 5% of children are underweight. The national average is only 2%. Persistent poverty is probably the explaining factor

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