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).
To examine those factors associated with the use of different types of ambulatory health services in a rural adolescent population.
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.
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.
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.
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- 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.
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.
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%.
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.
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 α 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 α 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 α = 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 α = 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 α = 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.
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.
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 χ2 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.
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%).
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.
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.
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).
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.
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).
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.
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- 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- 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- 8,13,16,21- 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- 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
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.
Corresponding author and reprints: Sheryl Ryan, MD, Department of Pediatrics, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621 (e-mail: firstname.lastname@example.org).
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