Amy Brock Martin

Disparities in Dental Insurance Coverage and Dental Care Among US Children: The National Survey of Children's Health

OBJECTIVES We sought to understand disparities in dental insurance coverage and dental care among US children by race/ethnicity, urban/rural residence, and socioeconomic status. METHODS Linked data from the National Survey of Childrens Health and Area Resource File were analyzed (N = 89 071). Multiple logistic regression analysis was used to adjust for confounders. RESULTS A total of 22.1% of US children lacked parentally reported dental insurance coverage in the preceding year, 26.9% did not have a routine preventive dental visit, and 5.1% had parentally perceived unmet need for preventive dental care. US born minority children were less likely to lack dental insurance than US-born white children; however, foreign-born Hispanic children were more likely to be uninsured. Rural children were more likely to be uninsured than urban children. Children with health insurance were more likely to have dental coverage. Children who lacked dental insurance were less likely to have received preventive care and more likely to have unmet need for care. Compared with US-born white children, all minority children were less likely to receive preventive care. These disparities were exacerbated among foreign-born children. Fewer race-based disparities were found for unmet need for dental care. Only black children, both US and foreign-born, had higher odds of unmet need for preventive services than US-born white children. Poor dental health was strongly associated with unmet need. Disparities in dental insurance coverage and dental care are also evident by family socioeconomic status. CONCLUSIONS Poor and minority children were less likely to receive preventive dental care, even when insurance status was considered. Rural children were less likely to have dental insurance than urban children. Foreign birth affected insurance status for Hispanic children and use of preventive services for all minority children.

The Prevalence of Violent Disagreements in US Families: Effects of Residence, Race/Ethnicity, and Parental Stress

CONTEXT. Witnessing domestic violence increases a childs chance of emotional or behavioral problems during childhood and entering abusive relationships in adulthood, even without co-occurring child maltreatment. OBJECTIVE. Our goals were to estimate the prevalence of reported violent disagreements in the homes of US children and to assess prevalence differences by race/ethnicity, residence, and reported parenting stress. PATIENTS AND METHODS. Data were drawn from the 2003 National Survey of Childrens Health. Case subjects with unknown gender, race/ethnicity, or residence were excluded, yielding 99660 observations. Disagreements were classified on the basis of how the family deals with serious disagreement. If disagreements involved hitting or throwing, even rarely, the household was categorized as having violent disagreements. Households reporting heated argument and shouting were classified as having heated disagreement. RESULTS. Nationally, 10.3% of children lived in homes with reported violent disagreements. Violent disagreements were most prevalent among black households (15.1%), followed by “other” (12.1%), Hispanic (11.3%), and white (8.6%) households. Urban areas had higher prevalence (10.7%) than did small through large rural counties (8.3%–9.9%). In multinomial logistic analysis, parents living in rural counties were less likely to report violent disagreements compared with those in urban. Black children were more likely to be exposed to both violent and heated disagreements than were white children. Parents reporting high parenting stress had higher odds of violent and heated disagreement than parents reporting less stress. CONCLUSIONS. A substantial number of children are exposed to violent disagreement. Although demographic and cultural factors may also influence disagreement style, parental stress seems instrumental in the development of violent disagreements. Parents who experience difficulty with parenting constitute a high-risk population. Helping parents understand and address child behavior may reduce such stress.

Relationship Between Presence of a Reported Medical Home and Emergency Department Use Among Children With Asthma

This study examined data from the 2005-2006 National Survey of Children with Special Health Care Needs to assess the relationship among children with asthma between a reported medical home and emergency department (ED) use. The authors used 21 questions to measure 6 medical home components: personal doctor/nurse, family-centered, compassionate, culturally effective and comprehensive care, and effective care coordination. Weighted zero-inflated Poisson regression analyses assessed the independent effects of having a medical home on annual number of child ED visits while controlling for child and parental characteristics, and the differential likelihood of securing a medical home. Nearly half (49.9%) of asthmatic children had a medical home. Receiving primary care in a medical home was associated with fewer ED visits (incidence rate ratio = 0.93; 95% confidence interval = 0.89-0.97). A medical home in which physicians and parents share responsibility for ensuring that children have access to needed services may improve child and family outcomes for children with asthma.

Patterns of engagement in care by HIV-infected adults: South Carolina, 2004-2006.

Objective:Identify factors associated with HIV care utilization in South Carolina. Design:Cross-sectional analysis of South Carolina nonpregnant HIV-infected individuals (N = 13 042) for the period 1 January 2004 to 31 December 2006. Methods:Reporting of HIV laboratory markers is legally mandated in South Carolina. Individuals with reported viral load tests or CD4 cell counts during a calendar year were defined as ‘in HIV-medical care’ that year. Care utilization categories were in care, care all 3 years; not-in-care (NIC), no care received; and transitional care, during some but not all years. Multinomial logistic regression using generalized logits was used to estimate relationships between care utilization and predictor variables. Results:Five thousand, two hundred and seventeen (40.0%) of South Carolina HIV-infected adults were NIC and 3300 (25.3%) were in transitional care during 2004–2006. Although a larger number of black than white HIV-infected adults were NIC, adjusted odds for NIC status were lower among blacks than whites [adjusted odds ratio (AOR), 0.82; 95% confidence interval 0.74, 0.92)]. Women had lower odds of being NIC than men (AOR, 0.66; 95% confidence interval 0.58, 0.74). Compared with individuals 55 years or older, individuals who were 25–34 years old were most likely to demonstrate both the NIC (AOR, 1.85; 95% confidence interval 1.29, 2.65) and transitional (AOR, 1.85; 95% confidence interval 1.31, 2.62) care patterns. Conclusion:Large proportions of the South Carolina HIV-infected adult population are not consistently accessing HIV-medical care. Targeted programs are needed to improve engagement for HIV-infected adults most likely to transition or not be in care.

The metabolic syndrome: are rural residents at increased risk?

PURPOSE The purpose of this study was to estimate the differences in prevalence of metabolic syndrome and its individual components across rural-urban populations, as well as to determine the risk factors associated with metabolic syndrome and examine how they contribute toward rural-urban disparity. METHODS Data came from the 1999-2006 National Health and Nutrition Examination Survey, restricting to 6,896 participants aged 20 years or more with complete information. Metabolic syndrome was defined using the National Cholesterol Education Programs Adult Treatment Panel III criteria. Residence was measured at the census tract level using the Rural-Urban Commuting Area Codes. We estimated the prevalence of metabolic syndrome and its components by residence. Multiple logistic regression models were used to examine urban-rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors. RESULTS The prevalence of metabolic syndrome was higher in rural than urban residents (39.9% vs 32.8%), among both men (39.7% vs 33.3%) and women (40.2% vs 32.3%, respectively). The age and sex adjusted OR for metabolic syndrome in rural as compared to urban residents was 1.23 (95% CI, 1.02-1.49), which was attenuated to 1.06 (95% CI, 0.90-1.25) after adjusting for covariates. Older age, lower physical activity, higher screen time, higher meat intake, and skipping breakfast were associated with increased odds of metabolic syndrome. CONCLUSION Rural dwelling was associated with higher prevalence of metabolic syndrome among adults in the Unites States, which can be attributed to the differences in demographic composition and obesity-related behavioral factors between urban and rural residents.

Differences in Readiness Between Rural Hospitals and Primary Care Providers for Telemedicine Adoption and Implementation: Findings From a Statewide Telemedicine Survey

PURPOSE Published advantages of and challenges with telemedicine led us to examine the scope of telemedicine adoption, implementation readiness, and barriers in a southern state where adoption has been historically low. We hypothesized that rural hospitals and primary care providers (RPCPs) differ on adoption, readiness, and implementation barriers. We examined the degree to which they differ on (a) telemedicine adoption or readiness; (b) telemedicine training needs; (c) current use of technology for patient care; and (d) environmental concerns in facilities for telemedicine. METHODS Paper surveys were sent to rural hospitals and RPCPs with response rates of 50% (n = 38) and 25.9% (n = 339), respectively. Three of 4 hospitals were represented. Chi-square analyses were used to test for differences between rural hospitals and RPCPs. FINDINGS Compared to RPCPs, rural hospitals were significantly more likely to report higher rates of telemedicine knowledge (P= .0007); planning for or implementing telemedicine (P < .0001); and reporting their disaster recovery data systems (P= .0002) and availability and location of outlets and connections (P= .03) as adequate for telemedicine. Rural hospitals were less likely to report having no telemedicine education needs (P= .04). CONCLUSIONS Telemedicine continues to be a viable solution for bridging geographic access gaps to a variety of specialty care. Users need assistance in understanding legal implications, care coordination, billing for services, and disaster data recovery. In rural areas, hospitals appear to best embody characteristics of facilities that successfully implement telemedicine and have the greatest degree of readiness.

Violence and Drug Use in Rural Teens: National Prevalence Estimates From the 2003 Youth Risk Behavior Survey

OBJECTIVES The purpose of this study was to compare national estimates of drug use and exposure to violence between rural and urban teens. METHODS Twenty-eight dependent variables from the 2003 Youth Risk Behavior Survey were used to compare violent activities, victimization, suicidal behavior, tobacco use, alcohol use, and illegal drug use across rural, urban, and suburban teens across the country. RESULTS Overall, rural teens were equally or more likely than both suburban and urban teens to report experiencing many measures of violent behavior, victimization, suicide behaviors, and drug use. Among all teens, nonwhites reported equal or higher rates of violent behavior and victimization than whites, but these associations disappeared within the rural-only population. CONCLUSIONS Rural areas do not appear to provide a strongly protective effect against risk behaviors in teens and may be a risk factor in itself. Community prevention efforts should focus on reaching rural areas and segmenting program content based on need. Where white teens might benefit from an emphasis on preventing tobacco and alcohol use, nonwhite teens would benefit from an emphasis on preventing violence and victimization.

Potentially Violent Disagreements and Parenting Stress Among American Indian/Alaska Native Families: Analysis Across Seven States

Objectives We examined the prevalence and correlates of potentially violent disagreements among AI/AN families with children. Methods We conducted a cross-sectional examination of data from the 2003 National Survey of Children’s Health, limited to seven states for which AI/AN race/ethnicity was available in public use files (Alaska, Arizona, Montana, New Mexico, North Dakota, Oklahoma, and South Dakota). Disagreements were classified based on how the family deals with conflict. If disagreements involved actual (hitting) or symbolic (throwing) violence, even rarely, the household was categorized as having “potentially violent disagreements,” with heated argument and shouting being classified as “heated disagreement.” Parenting stress and demographic characteristics were included as potential correlates. Results Potentially violent disagreements were reported by 8.4% of AI/AN and 8.4% of white families. The odds for potentially violent disagreements were markedly higher among parents reporting high parenting stress, in both AI/AN (OR 7.20; CI 3.45–15.00) and white (3.59, CI 2.71–4.75) families. High parenting stress had similar effects on the odds for heated discussion. Having a child with special health care needs was associated with parenting stress. Conclusions Questions about disagreement style may be useful as potential screens for domestic violence.

Continuity of Health Insurance Coverage and Perceived Health at Age 40

While a lack of health insurance or interrupted coverage has been shown to lead to poorer health status among preretirement populations, this phenomenon has not been examined among a large population of younger, working-age adults. We analyzed a nationally representative data set of persons born between 1957 and 1961, the National Longitudinal Survey of Youth—1979, to examine the links between insurance continuity and self-assessed physical and mental health at age 40. Among respondents turning 40 in 1998 or 2000, 59.8% had been continuously insured during the decade before they reached age 40. In unadjusted analysis, persons who were continuously covered had the highest scores for both physical and mental health. After controlling for respondent characteristics, insurance coverage was not significantly associated with perceived physical or mental health.

Maternal Obesity and Gestational Weight Gain in Rural Versus Urban Dwelling Women in South Carolina

PURPOSE An unhealthy prepregnancy weight and/or gaining an inappropriate amount of weight during pregnancy increase the risk for poor pregnancy and birth outcomes. To our knowledge, no studies to date have examined differences in prepregnancy body mass index (BMI) and gestational weight gain (GWG) patterns by rurality. METHODS The 2004-2006 South Carolina birth certificate data (n = 132,795) were used. Rurality of residence was determined using Rural-Urban Commuting Area (RUCA) codes. Mothers were categorized as underweight (<18.5 kg/m(2)), normal weight (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0) using their prepregnancy BMI and as having inadequate, adequate, or excessive GWG according to the Institute of Medicines 2009 GWG guidelines. Chi-square tests and adjusted multinomial logistic regression were used in analysis. FINDINGS Rural women had higher odds of being overweight and obese compared to urban women. This relationship was found to be partially explained by the higher proportion of minorities living in rural areas. The relationship between GWG and residence type varied by BMI category. Specifically, among normal weight women, rural women had increased odds of inadequate GWG. Among overweight women, rural women had decreased odds of excessive GWG. In obese women, rural women had decreased odds of both inadequate and excessive GWG. CONCLUSIONS Rural women were more likely to have an unhealthy prepregnancy weight than urban women. However, rural residence was found to be protective against unhealthy GWG in overweight and obese women. Future research exploring reasons for these findings and confirmation of these results in other populations is necessary.