OBJECTIVE. National recommendations by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners promote that all children obtain quality primary care through a consistent medical provider who can better assess, diagnose, and monitor a child's health. The purpose of this article was to identify characteristics of children in Florida without a personal health care provider.
METHODS. Florida data (N = 2116) from the 2003 National Survey of Children's Health were analyzed by using bivariate and multivariate methods. The dependent, or outcome, variable was a personal health care provider, defined in the National Survey of Children's Health as a personal doctor or nurse.
RESULTS. In Florida, 20.1% of children (0–17 years of age) do not have a personal health care provider compared with 16.7% in the United States. Children at greatest risk are those without health insurance. Other significant risk factors include family poverty up to 100% of federal poverty level, poverty level 100% to 199%, poverty level unknown, poverty level 200% to 399%, children aged 5 to 12 years, children aged 13 to 17 years, and Hispanic ethnicity. All the factors in the Florida model were also significant in the national model.
CONCLUSIONS. Lack of a personal health care provider is driven by larger community issues of health insurance, socioeconomic status, and ethnicity, including race, on a national level. To achieve the goal of a personal health care provider for children, a multifaceted approach needs to be considered. Knowing which children are without a personal health care provider provides valuable information for state policy-makers, program planners, and evaluators.
National professional organizations, including the American Academy of Pediatrics (AAP) and the National Association of Pediatric Nurse Practitioners, have established position statements to promote the attainment of quality primary care for all children and adolescents through a personal doctor or nurse, or through a personal health care provider.1,2 A personal health care provider can consistently assess, diagnose, and monitor a child's health.3,4 The provider can ensure continuity of care, offer a substantially higher level of comprehensive care compared with children without a personal doctor or nurse, and advance culturally effective care.5,6 A personal doctor or nurse who knows the child can refer her/him for both basic preventive services, such as oral health care, and specialty services if needed, such as speech and language evaluations, and monitor the outcome of referrals.
It is more efficient for children and adolescents to receive care from a personal doctor or nurse because the provider knows the child and can quickly ascertain changes in status and initiate treatment to prevent complications. The establishment of a personal doctor or nurse may decrease inappropriate use of the emergency department, further promoting effective use of health care dollars.7
A personal health care provider is one of the characteristics of a medical home as defined in a 2004 AAP policy statement.1Healthy People 2010 data suggests that 93% of children and youth 17 years of age and younger currently have a specific source of ongoing care, with the goal to increase the percentage to 97% by the year 2010.8
It was recently reported that 43.0% of Florida children have a medical home compared with 46.1% of US children aged 0 through 17 years of age, and that 83.3% of these children have a personal doctor or nurse compared with 79.9% of Florida children.9
Although others have examined factors associated with a medical home and components of a medical home, especially in relation to children with special health care needs,3,4 none have investigated the issue in the context of the theoretical framework of Aday and Andersen's Access to Medical Care model.10 The Aday and Andersen Access to Medical Care Model emphasizes that health policy can affect 2 inputs: characteristics of the health care delivery system and the populations at risk. These 2 inputs can change the 2 outputs of the model, the use of health care services and consumer satisfaction with the services.10 Investigating characteristics of the population at risk may lead to effective health policies that will improve use of health services. Through the National Survey of Children's Health (NSCH), we were able to study Florida children at risk of not having a personal health care provider.
The data used for the study are from the public-use data set for the 2003 NSCH, described briefly in the article by Kogan and Newacheck11 in this issue. There were 2116 completed interviews in Florida. Human subjects approval was given by the Florida State University Institutional Review Board, and the study was deemed exempt from review by the Florida Department of Health.
The dependent variable for the study was based on the question: A personal doctor or nurse is a health care professional who knows your child well and is familiar with your child's health history. This can be a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or a physician assistant. Do you have 1 or more persons you think of as [your child's] personal doctor or nurse? The 4 possible answers to this question were: “yes,” “no,” “don’t know,” and “refused.” The latter 2 responses were treated as missing values (n = 7).
The independent variables for the study were selected based on the 3 components of a population at risk in the Access to Medical Care model: predisposing, enabling, and need. The predisposing component includes variables that describe properties that exist before the onset of an illness; the enabling component describes the means and resources individuals and families have available to facilitate the use of services; and the need component refers to illness level.10 Additional variables were selected from the survey that reflected contemporary issues, such as whether the parents and/or child were born in the United States, primary language, and whether an interpreter is needed when accessing health care.
Initially, a total of 22 independent variables were selected. However, concerns about possible multicolinearity between child born in the United States, father born in the United States, mother born in the United States, primary language not English, and need for an interpreter when accessing health care services resulted in not including the above noted variables in the analysis. The results of the correlations analysis justified using Hispanic ethnicity because relatively high correlation was noted with the following 4 variables for both the US and Florida data sets: Hispanic, mother not born in the United States, father not born in the United States, and primary language not English.
The following were predisposing factors:
child's age (defined as <1, 1–4, 5–12, or 13–17 years of age);
ethnicity (defined as Hispanic or not Hispanic);
race (defined as black, not black, or unknown);
family structure (defined as 2-parent family, meaning 2 biological parents or a biological/stepparent family, and a single-parent family, meaning a 1-parent family); and
education level of highest member in household (defined as less than high school, high school graduate, or more than high school).
The following were need factors:
Presence of a moderate or severe chronic condition: the child had to have at least one of the common acute and chronic conditions listed in subdomain 3 of the NSCH and a severity rating of moderate or severe. The conditions included learning disability, emotional, behavioral, and physical conditions.
Presence of a special health care need: a special health care need was defined as the child needing 1 or more of the 5 indicators from Children with Special Health Care Need Screener in subdomain 2 of the NSCH: prescription medications, special services, physical limitation, special therapy, and counseling. The special need lasted or was expected to last 12 months or longer and was because of a medical, behavioral, or other health condition.
The following were enabling factors:
poverty status (defined as below poverty level, 100%–199% poverty level, 200%–399% poverty level, poverty level unknown, or poverty level of ≥400%); and
health insurance status (defined as health insurance with no gaps in past year, health insurance with some gaps in coverage the past year, or no health insurance).
SUDAAN software12 was used for the regression analysis to account for the complex sampling survey design. SAS software13 was also used to perform correlation functions not available in SUDAAN. Scaled or normalized weights were used for SAS functions such that the sum of the scaled weights was equal to the unweighted sample size, but the scaled weights were proportional to the complex sample weights.
Regression analysis was used to assess the independent association of the selected variables of the Access to Medical Care model with the dependent variable. The independent variables were examined by using logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Multicolinearity among all of the variables was assessed by using Pearson's correlation coefficient with scaled weights.
Sample and Population Characteristics
Overall, 20.1%, or an estimated 783000, of Florida children <18 years old did not have a personal health care provider compared with 16.7%, or an estimated 12078000, nationally. A significant difference was found between US and Florida children without a personal health care provider by using χ2 analysis (P = .0008). Table 1 presents weighted frequencies of Florida data for the dependent and independent variables in the model.
Table 2 presents the prevalence of no personal health care provider by each individual variable. As a child's age increased, the likelihood of not having a personal health care provider also increased. Florida children from households with a high school education or less were more likely to not have a personal health care provider compared with children from households with above a high school education. Florida children with reported gaps in health insurance coverage in the previous 12 months and those children with no health insurance have a higher percentage of not having a personal health care provider than did children with full health insurance coverage the past year. The percentage of Florida children without a personal health care provider decreased as the family's percentage above the federal poverty level increased. Hispanic children were also at a higher risk of not having a personal health care provider.
Results of the multivariate logistic regression analysis are provided in Table 3. Findings indicated the following Florida children are significantly more likely to not have a personal health care provider: children 5 to 17 years old, of Hispanic ethnicity, from families below the federal poverty level, from federal poverty levels between 100% and 399% and from unknown poverty levels, and children who did not have health insurance in the last 12 months. The lack of a personal health care provider was not noted for Florida children 1 to 4 years old (borderline significant for adjusted only), reporting a moderate or severe chronic condition, with a special health care need, black, from households with a high school education or less, and with health insurance gaps in the past year.
Differences Between Florida and the United States
Nationally, we found similar findings in addition to the following factors being significantly associated with not having a personal health care provider: children 1 to 4 years old, black, from single parent families, from households with a high school education or less, and children with gaps in health insurance coverage the past 12 months. US children with moderate or severe chronic conditions and with a special health care need were significantly less likely to not have a personal health care provider (US analyses are available on request).
Among all possible pairs of the independent variables, Pearson's correlation coefficients (r) >0.30 were found for only 3 pairs of variables for Florida data: (a) less than a high school education and federal poverty levels <100% (0.32), (b) more than a high school education and federal poverty level <100% (0.33), and (c) more than a high school education and federal poverty levels >400% (0.34). Multicolinearity was noted among an additional pair of US variables: less than a high school education and Hispanic ethnicity (0.36). We decided that the analytical value of these variables warranted including them in the model, although the correlations may result in larger CIs for the affected ORs.
The findings of this study support that mainly predisposing and enabling factors from the Access to Medical Care model were associated with Florida children not having a personal health care provider. Significant predisposing factors were children between 5 and 17 years of age, with adolescents at a higher risk, and Hispanic ethnicity. Significant enabling factors associated with Florida children not having a personal health care provider included: children from households below the federal poverty level, 100% to 199% of poverty level, 200% to 399% of poverty level, and unknown poverty level. Florida children with some health insurance coverage in past year were more likely to have a personal health care provider compared with children without insurance.
The findings support previous studies that a child's health status is not the only predictor of access to consistent health care and emphasize the need to implement a multifaceted approach to ensure access for all children.4,14–16 Although the Florida findings did not note significance with children who experienced gaps in health care coverage in the past 12 months, significance was noted in the US analysis. Previous studies have noted that gaps in health insurance coverage are as important a consideration as lack of health insurance.17,18 Studies have also documented the vulnerability experienced by children living in poverty, Hispanic children, and black children in accessing health care.19 The needs of adolescents for established medical care have been documented in the literature.20
Limitations of the study include the respondents’ correct understanding of the question pertaining to personal health care provider and questions about health conditions. Health conditions reported by parents or guardians were not confirmed through review of medical documentation. Hispanic ethnicity did not take into account cultural variations among groups who would identify as Hispanic.
A personal health care provider is an important component of the concept medical home. The Aday and Andersen Access to Medical Care model provides a conceptual framework to study access to a personal health care provider through examining one of the inputs in the model, characteristics of the population at risk, through predisposing, enabling, and need factors.
Analyzing characteristics of the at-risk population (ie, Florida children without a personal health care provider) can lead to effective health policy and, ideally, evidence-based interventions. For example, the model proposes that health policy influences the use of services by a risk population. Availability of health insurance is one such policy. Expanding child health insurance coverage through adding the State Children's Health Insurance Program has been shown to increase the percentage of children with a usual source of care.21 Such expansion reduces the hospitalization rate of children for ambulatory care sensitive conditions because of improved access to primary care.22 Important health policy considerations for Florida include addressing the need for full health insurance coverage for all children and maintaining uninterrupted health insurance coverage, especially as Florida explores Medicaid and State Children's Health Insurance Program reforms.
Policy recommendations could be directed toward children of Hispanic ethnicity or children living in poverty to ensure that vulnerable groups have a personal health care provider. These populations are at moderate-to-high risk for not having a personal provider, even after adjusting for each other, race, household education, number of parents, and health insurance. Access to health care for Hispanic/Latino children in the United States reportedly varies by country or region of origin and by generation resulting from immigration.23,24 Other access barriers suggested beyond the ones identified in this study include those related to the family: parental health beliefs, health behaviors, source of health advice, language problems, and cultural differences; and those related to the provider: language services, provider practices and behaviors, cultural competency, impaired quality of care, excessive waiting times, and proportionately fewer Hispanic health professionals.25,26 These issues suggest potential actions by both policymakers and providers in Florida. Another limitation of this study was that health insurance and income were the few enabling study variables available. Enabling factors are perceived to be more mutable and able to improve access.27 Future studies can address additional components of the Aday and Andersen model, such as the overall ability to access needed health care services and satisfaction with services received.
Another group in Florida at high risk for not having a personal provider is adolescents. Before the onset of sexual activity, teens generally need and use fewer preventive health services than young children. In other communities, not having a personal provider frequently relates to the variety of providers that teens can use and the potential use of different providers for different needs.28 Care for medically emancipated conditions and confidential services for adolescents are limited among primary care practices and significant disagreement between office staff and physicians over policies have been shown.29 Adolescents frequently do not receive needed care because of hiding issues from parents, potential costs, and time constraints.30 Health care alternatives are needed for Florida adolescents to ensure access to health care.
The Access to Medical Care Model can also identify strengths in current health policy. The findings that Florida children with a moderate or severe chronic condition and children with a special health care need did not significantly lack a personal health care provider could be viewed as an asset, because the results suggest current health policy and programs are ensuring that children with greater health care needs have access to a personal health care provider.
Pediatricians and collaborators can advocate to ensure that all children and adolescents have access to a personal health care provider. The NSCH can assist states and regions to study children at risk for not having a personal provider. Results from analyses can provide the foundation to support the development of evidence-based health policy.
- Accepted September 15, 2006.
- Address correspondence to Mary Beth Zeni, ScD, Florida State University, College of Nursing, 413 Duxbury Hall, Tallahassee, FL 32306. E-mail:
The authors have indicated they have no financial interests relevant to this article to disclose.
- ↵National Association of Pediatric Nurse Practitioners. The pediatric health care home. Available at: www.napnap.org/index.cfm?page=10&sec=54&ssec=68. Accessed April 16, 2006
- ↵Strickland B, McPherson M, Weissman G, van Dyck P, Huang ZJ, Newacheck P. Access to the medical home: results of the national survey of children with special health care needs. Pediatrics.2004;113(5 suppl) :1485– 1492
- ↵Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics.2004;113(5 suppl) :1493– 1498
- ↵Bethel C, Peck C, Abrams M, Halfon N, Sareen H, Collins KS. Partnering With Parents to Promote the Healthy Development of Young Children Enrolled in Medicaid: Results From a Survey Assessing the Quality of Preventive and Developmental Services for Young Children Enrolled in Medicaid in Three States. New York, NY: Commonwealth Fund; 2002. Available at: www.cmwf.org/publications/publications_show.htm?doc_id=221310. Accessed March 20, 2006
- ↵Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. Rev ed. New York, NY: Oxford University Press; 1998:1485–1492
- ↵US Department of Health and Human Services. Healthy People 2010. Conf ed. Washington, DC: US Department of Health and Human Services; 2000
- ↵National Survey of Children's Health. Data resource center: your data…your story. Available at: http://nschdata.org/DataQuery/DataQueryResults.aspx. Accessed December 1, 2006
- ↵Kogan MD, Newacheck PW. Introduction to the volume on articles from the National Survey of Children's Health. Pediatrics.2007;119(suppl 1)S1– S3
- ↵Research Triangle Institute. SUDAAN User's Manual, Release 8.0. Research Triangle Park, NC: Research Triangle Institute; 2001
- ↵SAS Institute Inc. SAS Release 9.1. Cary, NC: SAS Institute Inc; 2006
- Goldhagen J, Remo R, Bryant T, et al. The health status of Southern children: a neglected regional disparity. Pediatrics.2005;116 (6). Available at: www.pediatrics.org/cgi/content/full/116/6/e746
- ↵Newacheck PW, Stoddard MD, Hughes DC, Pearl M. Health insurance and access to primary care for children. N Engl J Med.338 :513– 519
- ↵Kogan MD, Newacheck PW, Honberg L, Strickland B. Association between underinsurance and access to care among children with special health care needs in the United States. Pediatrics.2005;116 :1162– 1169
- ↵Newacheck PW, Hughes DC, Stoddard JJ. Children's access to primary care: differences by race, income, and insurance status. Pediatrics.1996;97 :26– 32
- ↵Szilagyi PG, Dick AW, Klein JD, Shone LP, Zwanziger J, McInerny T. Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP). Pediatrics.2004;113 (5). Available at: www.pediatrics.org/cgi/content/full/113/5/e395
- ↵Burgos AE, Schetzina KE, Dixon B, Mendoza FS. Importance of generational status in examining access to and utilization of health care services by Mexican American children. Pediatrics.2005;115 (3). Available at: www.pediatrics.org/cgi/content/full/115/3/e322
- ↵Akinbami LJ, Gandi H, Cheng TL. Availability of adolescent health services and confidentiality in primary care practices. Pediatrics.2003;111 :394– 401
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