title: Context and healthcare access: looking beyond the individual.
abstract: BACKGROUND
  Although health is influenced by an individual's characteristics and choices, accumulating evidence suggests that contextual attributes may influence a variety of health outcomes. Whether these factors also represent "upstream" factors affecting one's ability to enter the healthcare system is less clear, however.
  
  
  OBJECTIVE
  The objective of this study was to assess associations between contextual characteristics and an individual's report of having a usual source of health care.
  
  
  METHODS
  Cross-sectional, survey-weighted data assessing demographics, insurance status, needs, and healthcare access were obtained through telephone survey in 1998 and were linked with county-level data from the 1998 Area Resource File and the 1990 US Census.
  
  
  METHODS
  A state-representative sample of 16,261 adult residents, living in urban, suburban, and rural settings throughout Ohio comprised this study.
  
  
  METHODS
  Operational measures for social, economic, and health system characteristics were used in multilevel logistic regression models to test associations with an individual's report of a usual source of care.
  
  
  RESULTS
  The weighted proportion of individuals reporting no usual source of care was 18.0%. Although individuals' current health, insurance status, income, demographics, educational attainment, and social support were closely associated with this outcome, significant associations remained for county-level characteristics representing the level of poverty and degree of urbanization.
  
  
  CONCLUSIONS
  Persisting health status disparities increase the need for programs that promote equitable access to health care. Policy interventions may be more effective if they look beyond individual characteristics to incorporate strategies that address economic factors in areas where healthcare access is inequitable.
authors.affiliation: Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio 44106, USA. David.Litaker@med.va.gov
authors.forename: David
authors.initials: D
authors.lastname: Litaker
authors.forename: Siran M
authors.initials: SM
authors.lastname: Koroukian
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Love
mesh_terms: D000328:Adult; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006302:Health Services Research; D006801:Humans; D019458:Insurance Coverage; D008297:Male; D008875:Middle Aged; D017059:Models, Econometric; D016017:Odds Ratio; D009820:Ohio; D011320:Primary Health Care / Q000191:economics / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors