title: Determinants of health care use by children in rural western North Carolina: results from the Mountain Accessibility Project.
abstract: 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 dollars per year had 76% more visits than those with incomes <20 000 dollars 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 dollars per year were associated with 2.5-fold increased health care visits, and those with household incomes between 20 000 dollars and 40 000 dollars per year had 2-fold increased health care visits, compared with those with household incomes <20 000 dollars 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.
authors.affiliation: Department of Pediatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina 27157-1084, USA. cwoods@wfubmc.edu
authors.forename: Charles R
authors.initials: CR
authors.lastname: Woods
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Arcury
authors.forename: James M
authors.initials: JM
authors.lastname: Powers
authors.forename: John S
authors.initials: JS
authors.lastname: Preisser
authors.forename: Wilbert M
authors.initials: WM
authors.lastname: Gesler
mesh_terms: D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data*; D002675:Child, Preschool; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007182:Income; D007223:Infant; D007348:Insurance, Health; D008297:Male; D008484:Medicaid; D015999:Multivariate Analysis; D009657:North Carolina; D044469:Racial Groups; D019035:Rural Health Services / Q000706:statistics & numerical data*; D012424:Rural Population