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The Effects of Regular Source of Care and Health Need on Medical Care Use Among Rural Adolescents
Sheryl Ryan, MD;
Anne Riley, RN, PhD;
Myungsa Kang, MS;
Barbara Starfield, MD, MPH
Arch Pediatr Adolesc Med. 2001;155:184-190.
ABSTRACT
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Objective To examine those factors associated with the use of different types
of ambulatory health services in a rural adolescent population.
Methods The student bodies of 2 middle schools and 2 high schools in rural areas
in a mid Atlantic state (N = 1615) were surveyed using a self-administered
health status and health services use instrument. Logistic regression was
used to assess factors predicting receipt of (1) preventive services, (2)
problem-focused services, and (3) emergency services.
Results One third of the rural youth reported having received preventive services
within the previous 3 months; 41% received problem-focused care, and 18% received
emergency services. Having the same provider for both preventive and illness
care was the most consistent and significant predictor of receipt for all
types of ambulatory services. Of special note is the greater use of emergency
services when subjects did not have a consistent provider for both preventive
and illness care. Health need variables, measured across a wide range of domains,
were additionally predictive, and their significance varied according to the
type of services received.
Conclusions This study provides compelling evidence that for rural adolescents,
having a regular source of care and medical need are the most important predictors
of use across a variety of types of ambulatory care.
INTRODUCTION
IN THE CURRENT era of restructuring the delivery of health care and
recognizing the importance of cost containment, health care systems are increasingly
being required to demonstrate their ability to maintain or improve health
outcomes and the general well-being of the populations served. For health
care facilities to meet these demands, many questions must be answered regarding
the way in which individuals use health services, the factors that most strongly
predict use of different types of services, and their effect on satisfaction
with care, perceptions of one's health, and overall health status. Few studies,
however, have examined the differences in determinants across a variety of
ambulatory services, such as preventive health care, short-term or follow-up
medical care that is problem focused, and emergency care.
Aday and Andersen's behavioral model has frequently been used as a framework
to evaluate the use of and access to personal health services.1
This model suggests that the use of personal health services results from
commonly recognized determinants such as individual predisposing factors (age,
gender, race/ethnicity, education), characteristics enabling use (health insurance,
family composition, family income, having a regular source of care), and the
need for medical care.1
The purpose of this study was to examine predictors of different types
of ambulatory medical service use in a school-based adolescent population
in a rural environment. We chose to focus this report on rural youth since
few studies have examined access to and use of medical services among youth
in nonurban settings, and the limited studies that have been completed suggest
that nonurban youth face considerable barriers to obtaining needed medical
care.2 Relying on previously published studies,
we identified the factors associated with 3 different types of ambulatory
visits: preventive care, problem-focused medical care (either short-term or
follow-up), and emergency care.3, 4, 5, 6, 7, 8
We tested 2 hypotheses: (1) predictors of use will vary by type of ambulatory
services for adolescents, with perceived health and personal health practices
associated with preventive services, and diagnosed disorders, symptoms, and
activity limitations associated with problem-focused and emergency care; and
(2) rural youth will have greater barriers to care access and lower rates
of service use than those reported in previous studies using nonrural samples.
SUBJECTS AND METHODS
STUDY POPULATIONS
The adolescents in this study (N = 1615) included the entire student
body of 4 secondary public schools (2 middle schools and 2 high schools) in
the westernmost county of Maryland. This rural county is one of the poorest
counties in Maryland and is surrounded by rural areas. The largest town had
fewer than 2000 residents in 1990. Data were collected in December 1992.
Gender was fairly evenly divided, as was age, although there were smaller
numbers of adolescents in the 10- to 13-year-old age groups (Table 1). The racial/ethnic composition of the sample reflects the
racial/ethnic makeup of the geographic area represented, with the sample comprising
almost exclusively white subjects (97.3%). Students were mainly from families
in the low- to mid-socioeconomic ranges and were most likely to be in households
with both biological parents present.
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Table 1. Sociodemographic, Access, and Utilization Characteristics
in 1615 Subjects*
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DATA COLLECTION
Prior to administration of the health and utilization surveys in the
schools, parents of students were mailed information explaining the survey.
The survey was then administered in school classrooms to all students whose
parents did not object to their taking the survey and who themselves agreed
to participate; this procedure was approved by the school system and the university
institutional review board. The surveys were then administered by teachers
and completed anonymously by students in an extended homeroom period. The
response rate was 89%, with refusals consisting of 5% and absences, 6%.
MEASURES
The Child Health and Illness Profile–Adolescent Edition (CHIP-AE)
(Johns Hopkins University, Baltimore, Md),9, 10
was used to comprehensively measure health status and sociodemographic variables.
Health need was operationalized based on the CHIP-AE. The CHIP-AE was developed
to measure 6 domains of health status across diverse populations of youth
aged 11 to 18 years. The development and psychometric properties of this instrument
have been described previously.9, 10
A modified version of the Health Service Use Survey (HSUS) was developed for
specific use with the CHIP-AE and provided data on the utilization of medical
services and the availability of a regular source of care.11
The HSUS is a self-administered survey designed for adolescents to report
their use of health services, independent of a report from their parents.
Predictor Variables
The predisposing characteristics and family background variables were
age, gender, race/ethnicity, head of household, mother's education level,
and family income level, defined as participation in free or reduced-cost
lunch programs. The enabling variable, regular source of care, was a summary
variable that incorporated 3 items from the HSUS regarding the availability
of a regular source of care. Adolescents were asked 3 questions about their
usual source of care: (1) whether there was one place where they usually went
for regular medical care, (2) a place they went for illnesses, and
(3) if
these places were the same. On the basis of responses, 4 categories were coded:
(1) had 1 source for both preventive and illness care; (2) had a regular source
for both preventive and illness care, but not the same; (3) had a regular
source for either preventive or illness care, but not both; and (4) did not
have a regular source for either.
Medical need was based on actual subdomain scores from several domains
of the CHIP-AE, using the scores as continuous variables, except for the Disorders
domain. The Emotional and Physical Discomfort subdomains of the Discomfort
domain measured symptom experience; the internal consistency reliability coefficients
for the Emotional and Physical Discomfort subdomains as measured by Cronbach 
are 0.93 and 0.88, respectively. The Limitation of Activity subdomain assessed
health-related days missed from school and reduction in normal activities,
and had a Cronbach of 0.66. To measure self-perceived
health, we used both the 5-point response of rating health from excellent
to poor, and the subdomain of Satisfaction With Health (Cronbach =
0.87) of the Satisfaction domain. Lifestyle behaviors that potentially increase
health need were assessed with the Individual Risk Behaviors and Threats to
Achievement Behaviors (delinquent activities) subdomains (Cronbach
= 0.84 and 0.89, respectively) of the Risks domain. For specific family health behaviors postulated to modify health need, we used the
subdomain index of Home Safety and Health from the Resilience domain (Cronbach
= 0.56). The Disorder domain and the subdomains of Acute Minor, Acute Major,
Recurrent, Long-Term Medical, Long-Term Surgical, and Psychosocial Disorders
were the basis for computing the number of different types of conditions a
teenager had. An algorithm for these ambulatory diagnostic groups (ADGs) computed
the number of ADG reported by each subject.12
Scores for each subdomain were obtained by summing each subject's responses
when at least 70% of items were answered. Subdomains were scored in the direction
of their titles, with higher scores indicating more and lower scores indicating
less of the specific construct.
Dependent Variables
The dependent variables of use of ambulatory services were constructed
from HSUS items regarding the type of care obtained in the previous 3 months.
The presence or absence of preventive care was based on whether a routine
physical examination, a sports or camp physical, or immunizations had been
obtained. Preventive care for females also included routine family planning
and gynecological checkups. Use of problem-focused care was measured by whether
the subject had received care for a medical problem, illness, or injury, or
had a follow-up visit for any of these. Use of emergency care was determined
by whether the individual reported having been to an emergency department.
DATA ANALYSIS
A 3-step data analytic plan was developed. Initially, the intercorrelates
of all the independent variables were assessed to identify problems of multicollinearity.
Bivariate analyses were then conducted to determine the relationship between
each of the 3 utilization variables and the predictor variables, using  2 analyses or analyses of variance, as appropriate. Finally, a multiple
logistic regression analysis was conducted for each type of service to estimate
the effect of each factor beyond that of all other factors in the model. All
of the covariates that were significant at P<.10
in the bivariate analyses were entered simultaneously into the multivariate
models. Several interaction terms that were initially included on the basis
of previous studies were subsequently dropped as they did not contribute significantly
to the models.
RESULTS
RATES OF UTILIZATION FOR AMBULATORY SERVICES
Fewer than one third of the subjects in the sample reported having the
same medical provider as their regular source of care for both preventive
and problem-oriented care, and fewer than one-quarter reported having a regular
source for preventive care only; 21.5% reported having no regular source for
either preventive or illness care (Table
1). One third of the subjects reported having received preventive
health care, with greater numbers reporting having received problem-focused
care (41.1%).
BIVARIATE ANALYSES
All of the predictor variables tested had a value of P<.10 for at least 1 of the types of services being evaluated and
were subsequently used for the logistic regression models (data available
on request). We also included race as a controlling variable rather than as
an explanatory variable as there was so little variance within the sample.
LOGISTIC REGRESSION ANALYSES
Preventive Services
Of the sociodemographic variables tested, both age and mother's education
were significantly associated with receiving preventive care (Table 2). Those aged 14 to 15 years were 1.5 times more likely to
have received care as those aged 10 to 13 years, and adolescents whose mothers
had not graduated from high school were 1.7 times less likely (odds ratio
[OR], 0.58) to have received preventive care than those whose mothers were
college graduates.
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Table 2. Factors Predicting Receipt of Preventive Care in 1615 Subjects*
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The likelihood of receiving preventive care was similar for those who
only had a regular source of care for preventive care and those with a regular
source of care for both preventive and illness care. However, those reporting
that they did not have a regular source of care for either preventive or illness
care were almost 4 times less likely to have received preventive care (OR,
0.26) than those with the same source for both preventive and illness care.
Additionally, those reporting that they had a regular source of care for illness
but not preventive care were about 3 times less likely (OR, 0.34) to have
received any preventive care within the previous 3 months.
Overall satisfaction with health was significantly associated with receipt
of preventive care; those who reported greater satisfaction with their health
were more likely to have received preventive care (OR, 1.7). Additional need
variables that were significant included the number of different types of
diagnosed conditions, as measured using the ADGs, and family health behaviors
as measured by the Home Safety and Health domain. Those reporting 4 to 5 types
of conditions vs reporting 0 or 1 and those reporting a greater number of
positive family health behaviors were significantly more likely to have received
preventive care (ORs, 1.7 and 1.4, respectively) (Table 2).
Problem-Focused Services
None of the sociodemographic factors were significant predictors of
having received problem-focused medical care (Table 3). The enabling factor of a regular source of care was highly
significant, however. Those reporting that they had no source of care for
preventive or illness care and those reporting that they had a regular source
of care for preventive but not illness care were almost 4 times less likely
and half as likely, respectively, to have received problem-focused care compared
with those with the same source of care for both preventive and illness services.
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Table 3. Factors Predicting Receipt of Problem-Focused Care in 1615
Subjects*
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Five need factors were associated with problem-focused care. Greater
satisfaction with overall health and reporting one's health as good compared
with excellent were associated with a lower likelihood of having received
care. Greater levels of limitations of activity, higher numbers of categories
of diagnosed conditions, and higher scores on the individual risk behavior
scale were associated with greater likelihood of having received problem-focused
care. The odds of seeing a medical provider increased with the number of ADGs
reported: those reporting 4 to 5 and 6 or more different types of disorders
(ADGs) were 1.9 and 2.2 times more likely to have received problem-focused
medical care compared with those reporting 0 or 1 disorder (Table 3).
Emergency Services
Those reporting having different sources of care for preventive services
vs illness needs were 1.8 times more likely to have received care in an emergency
setting than those with a consistent source of health care (Table 4). Greater numbers of diagnosed conditions, higher scores
on the Individual Risk Behavior subdomain scale, and lower scores on the Threats
to Achievement subdomain scale were all associated with a greater likelihood
of having received emergency services.
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Table 4. Factors Predicting Receipt of Emergency Services in 1615 Subjects
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COMMENT
In this study, we demonstrated that factors predicting use vary according
to the specific type of ambulatory services used, thus confirming our first
hypothesis. For all of the types of services studied, the variable assessing
regular source of care was consistently one of the most significant predictors.
Rural youth who did not have a regular source of care were 4 times less likely
to obtain both preventive and illness care. Having a regular provider for
only a specific type of care (eg, illness care) significantly reduced the
likelihood that youth had obtained the other type of care (eg, preventive
care). Finally, having a different source of care for preventive and illness
care almost doubled the likelihood that youth had used emergency services.
These findings suggest that when adolescents lack a single source of care
for both preventive and illness concerns, less preventive and problem-focused
care is obtained. Moreover, with the fragmentation that occurs when different
sources provide different types of services, medical services may be more
likely to be received in the emergency setting.
These findings are consistent with prior work conducted in both pediatric
and adult populations demonstrating the importance of a regular source of
care in ensuring the receipt of preventive services and timely illness care
and limiting inappropriate emergency room use.2, 13, 14, 15, 16
The ability to identify a regular source for care demonstrates the presence
of longitudinality, an essential attribute of primary care, and represents
the existence of a "personal relationship over time, regardless of the type
of health problem or even the presence of a health problem"17
between a patient and a physician or group of medical providers. Because we
measured the use of services and identification of a regular provider retrospectively,
it is possible that those who used services most recently were able to identify
a provider whom they reported to be a regular source, thus increasing the
relationship between provider and visits. However, the fact that we observed
significant but different patterns of relationships between a regular source
of care with each type of care suggests that the data are not biased by simultaneous
recall of provider and visit.18
Additional studies also support the importance of having a regular source
of care relative to additional factors such as socioeconomic status and health
insurance coverage.11, 19, 20, 21
Bartman et al,19 using a sample of adolescents
from the National Medical Care Expenditure Survey, found that inequities in
accessing ambulatory services were associated more with lacking a usual source
of care than socioeconomic factors. O'Malley and Forrest20
also found that receipt of pediatric preventive services in community health
centers was greater for those who identified the community health center as
their regular source for both preventive and illness care. Ryan et al11 found that having a regular source of care and not
health insurance was associated with a 2-fold greater likelihood of an adolescent's
having received preventive care in the previous 2 years.
Numerous studies have documented the role of medical need, such as poorer
perceived health, greater number of chronic conditions, and greater variety
of types of morbidity in promoting greater use of ambulatory services.3, 4, 5, 6, 7, 8, 13, 16, 21, 22, 23, 24, 25, 26
Because we were able to measure medical need using a variety of constructs,
we were able to demonstrate that different aspects of need vary in significance
in predicting use of service depending on the type of ambulatory services
being sought. For example, while the number of morbidity conditions was consistently
predictive across all 3 types of ambulatory care, other aspects of need were
related more specifically to each of the types of care. The association of
both greater satisfaction with one's health and involvement in family health
behavior with receiving preventive care suggests that adolescents who report
good health may be more motivated to maintain their health through preventive
care or that better health satisfaction may be a result of having recently
received preventive care. In contrast, the association of lower satisfaction
with health, greater limitations of activity, and greater involvement in risk
behaviors with problem-focused care suggests the importance of specific behavioral
factors and outcomes of medical problems among youth.
The overall rates of using medical care and having a regular source
of care reported by this rural sample are also significantly lower than those
reported by other urban or nonurban adolescent samples, confirming our second
hypothesis. For example, Ryan et al11 found
that 53% of urban adolescents reported having a regular source of care, and
70% reported having seen a physician within the previous 12 months, rates
that are higher than those observed in the current sample. McManus et al27 also found, using data from the National Health Interview
Survey, that significantly more rural than urban adolescents had no physician
contacts within the previous year (32.6% rural vs 28.5% urban).
Although no studies have been published to date evaluating the factors
that account for different rates of utilization of services in adolescents
across geographic settings that include both rural and urban youth, the wide
range of predictive factors found across types of services in this rural sample
may be explained in part by the low levels of access to care reported by this
population. Given this limited availability of services, a greater range of
factors or conditions representing "medical need" may be required before individuals
are able to access the medical system. These data suggest that in the face
of barriers to care, need, as manifested by perception of health or numbers
of types of conditions, may not be sufficient to ensure receipt of care. Additional
health needs, including the perception of one's health, the limitations of
activity that are experienced, or individual or family health behaviors, may
be required.
Few sociodemographic factors were significantly associated with use
of services, a finding that differs from prior work supporting the importance
of these factors.1, 2, 3
It may be explained by the wealth of information on need for medical care
reported by the adolescents, thus explaining the so-called gender effects
by characterizing various aspects of need for medical care. Mother's education
was the most significant of the demographic factors; this may reflect less
understanding regarding how to care for their children's health or, alternatively,
maternal education may be acting as a proxy for financial resources, which
were not directly assessed.
Several limitations to this study deserve comment. First, we were unable
to independently ascertain the actual use of services and actual source of
care through record review, relying instead on self-reporting. We used, however,
a 3-month recall period to enhance accurate recall of the services used. Also,
single visits reported may have been for both prevention and problem-focused
care. Nevertheless, unlike most studies of adolescent populations that rely
on parent responses, particularly those from national datasets, adolescents'
reports are likely to increase the likelihood that services received in school
or confidentially will be included. Also, although our school-based sample
had a low rate of school absences, we were not able to survey those either
absent or not enrolled who may represent youth with differing medical care
use and access patterns than those regularly attending school. It has previously
been shown that adolescents are inaccurate reporters of their health insurance
coverage, and because adolescents were the sole respondents in this study,
we chose not to include this as an enabling variable.28, 29
Finally, as previously discussed, the use of a cross-sectional design did
not allow for the interpretation of causal relationships. Despite these limitations,
the overriding strengths of this study include the separation of medical services
into 3 distinct types and the use of a well-validated instrument to measure
medical need more comprehensively.
In summary, our findings make it clear that factors such as having a
regular source of care and medical need exert critical but differential effects
on the use of ambulatory services. The relative importance of these factors
depends in part on the specific nature of the services being sought and the
availability of health services in a geographic area. The effects of longitudinality,
or having a regular provider, emphasizes that for adolescents, economic resources
alone may not be adequate to insure appropriate and timely access to medical
care. Since patterns regarding health care use adopted during adolescence
may continue into adulthood, our understanding of the relationship between
medical care need and enabling factors and the use of health and medical care
will enhance our ability to best provide those services needed to promote
the health and well-being of adolescents and young adults.30
AUTHOR INFORMATION
Accepted for publication October 4, 2000.
The research was supported through the University of Maryland Designated
Research Initiative Fund (Dr Ryan) and the Agency for Healthcare Research
and Quality, grant RO1-H507045 (Drs Ryan, Riley, and Starfield).
We acknowledge the contribution of the entire CHIP development team
at Johns Hopkins School of Hygiene and Public Health and Susan Davis, MEd,
of the Western Maryland Area Health Education Center for their valuable assistance
in data collection. We also thank Angela Kalish for her assistance with preparation
of the manuscript.
From the Division of Adolescent Medicine, University of Rochester School
of Medicine and Dentistry, Rochester, NY (Dr Ryan); and the Department of
Health Policy and Management, Johns Hopkins School of Hygiene and Public Health,
Baltimore, Md (Drs Riley and Starfield and Ms Kang).
Corresponding author and reprints: Sheryl Ryan, MD, Department of
Pediatrics, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621
(e-mail: sheryl.ryan{at}viahealth.org).
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