Determinants of Health Care Use by Children in Rural Western North Carolina: Results From the Mountain Accessibility Project Survey

Objective. To assess determinants of health care visits among children in a 12-county region of western North Carolina representative of rural areas in the United States. Methods. Households were randomly selected for surveys of household characteristics, health status, and health care use. Surveys were conducted June 1999 to January 2000 and were stratified for children younger than 5 years and 5 years and older. The number of health care visits in the year before the survey was used as the outcome measure. Weighted mean visits and associations of family demographic and child health variables with the number of visits were determined by ratio and multivariate survey regression methods. Results. Among children who lived in rural Appalachian regions of North Carolina in 1999, 90% had either public or private insurance coverage. The mean number of visits per child was 5.7 (median: 2.6), and in each age group the number of visits in the previous year exceeded the recommended number of well-child visits. There were no apparent geographic access barriers to care in this population, in that increased distances to provider sites did not result in declining numbers of visits. For children younger than 5 years, the primary determinants of health care use during the previous year were age, insurance status, and household income. Infants had more visits than older, preschool children, and those with household incomes >$40 000 per year had 76% more visits than those with incomes <$20 000 per year. Children with public insurance, exclusively Medicaid in this population, had almost 4 times as many visits as uninsured children. Among the children and adolescents 5 through 17 years of age, health insurance status, household income, pain during the past month, and race were the primary determinants of health care use during the previous year. Those with public health insurance had 6 times more health care visits than uninsured children. Household incomes >$40 000 per year were associated with 2.5-fold increased health care visits, and those with household incomes between $20 000 and $40 000 per year had 2-fold increased health care visits, compared with those with household incomes <$20 000 per year. White children had almost twice as many visits in the past year as black children in this age group. Pain experienced during the past month, as perceived by the parent, also predicted the number of visits in the older age group. Conclusions. This rural population seems to have reasonably good access to care overall. The key determinants of health care use among these rural children were similar to those found in urban and other populations in the United States and likely are universal: health insurance coverage, household income, and parent perceptions of their child’s pain. As in other populations, programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health. Differential use of health care among white and black children, especially those 5 years and older, merits additional explanation. Pediatrics 2003;112:e143–e152. URL: http://www.pediatrics.org/cgi/content/full/112/2/e143; rural health, child health, health insurance, race/ethnicity, pain. ABBREVIATIONS. NHIS, National Health Interview Survey; MAP, Mountain Accessibility Project; SDE, standard deviational ellipse; CI, confidence interval; IDR, incidence density ratio; MEPS, Medical Expenditure Panel Survey. An estimated 21% of children in the United States (approximately 16 million in 1996) live in rural areas.1 Larger proportions of children in the South and Midwest live in rural areas than in the Northeast and West. People who live in rural areas are health disadvantaged in several ways compared with their urban counterparts.2,3 These disadvantages include limited access to health care as a result of geographic barriers, such as time and distance to care sites, and availability of transportation. Even privately insured children in rural areas were less likely to have physician visits in the previous year than their urban/suburban counterparts in the 1990 National Health Interview Survey (NHIS).4 Health care for Americans who live in rural areas has been the subject of much policy discussion during the past 40 years, with the needs to increase access to services through public insurance programs and availability of services receiving the majority of the focus.2,5,6 In 1998, rural areas tended to have more family and general physicians but fewer physicians of all types than urban areas.7 Specialty health services for children and adults, both outpatient and inpatient, are less readily available to rural children than those who live in metropolitan areas. The end result is that rural-nonmetropolitan children are more likely to have unmet medical needs than children who live in From the Departments of *Pediatrics and ‡Family and Community Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina; and the Departments of §Biostatistics and Geography, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Received for publication Nov 11, 2002; accepted Apr 21, 2003. Reprint requests to (C.R.W.) Department of Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC 27157-1084. E-mail: