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Factors associated with use of preventive dental and health services among U.S. adolescents1
JOURNAL OF ADOLESCENT HEALTH 2001;29:395– 405
ORIGINAL ARTICLE
Factors Associated With Use of Preventive Dental and Health Services Among U.S. Adolescents STELLA M. YU, Sc.D., M.P.H., HILARY A. BELLAMY, M.P.H., RENEE H. SCHWALBERG, M.P.H., AND M. ANN DRUM, D.D.S., M.P.H.
Purpose: To examine adolescents’ use of preventive medical and dental services and its relationship to demographic characteristics and other variables reflecting access to and need for care. Methods: Self- and parent-reported data from a sample of 5644 adolescents aged 11 to 21 years from the National Longitudinal Study of Adolescent Health (Add Health). Variables studied include the influence of both the adolescents’ demographic and socioeconomic characteristics (age, race/ethnicity, place of birth, acculturation, insurance status, and perception of health), as well as those of their parents (race/ethnicity, income, level of education, place of birth) on their lifetime use and use within the past year of medical and dental services. Bivariate and logistic regression analyses were conducted using SAS and SUDAAN. Results: Approximately 32% of respondents had not had a physical examination in the year before the survey, and the same percentage had not had a dental examination. Approximately 2% reported never having had either a physical or a dental examination. Logistic regression reveals that lack of insurance, low family income, and low parental education level are significantly associated with the lack of preventive medical care. Lack of an annual dental visit was associated with male gender; black, Hispanic, or mixed race/ethnicity; and lack of insurance. Never having had a dental visit was the only
From the Maternal and Child Health Bureau, Office of Data and Information Management, Rockville, Maryland (S.M.Y., M.A.D.); and the Maternal and Child Health Information Resource Center, Washington, D.C. (H.A.B., R.H.S.). Address correspondence to: Stella Yu, Sc.D., M.P.H., Maternal and Child Health Bureau, Office of Data and Information Management, 5600 Fishers Lane, 18A-55, Rockville, MD 20857. The opinions expressed in this paper are the authors’ and do not necessarily reflect the views or policies of the institutions with which the authors are affiliated. Manuscript accepted March 29, 2001.
dependent variable found to be associated with place of birth. Conclusions: Health insurance and family income are most consistently related to adolescents’ use of preventive medical and dental care. However, the relationship between lack of dental care and place of birth emphasizes the need to improve access to dental services for immigrant teens. These findings are particularly relevant as states design systems of care for adolescents under the State Children’s Health Insurance Program. © Society for Adolescent Medicine, 2001 KEY WORDS:
Adolescents Prevention Dental care Immigrants
Adolescents are among those least likely to use health services [1]. The American Academy of Pediatrics, the American Medical Association, and the Health Resources and Services Administration’s Bright Futures Guidelines for Infants, Children and Adolescents recommend a routine preventive visit each year for adolescents from ages 11 through 21 years [2– 4]. However, research [5– 8] suggests that a substantial proportion of adolescents do not receive care with this frequency. This may be owing to factors related to the acceptability of the services themselves, to confidentiality and sensitivity to adolescents’ health concerns, or to lack of access to care for financial or geographic reasons. Moreover, adolescents’ access to preventive medical and dental care and treatment services may vary by their race, ethnicity, age, family income, and insurance status.
© Society for Adolescent Medicine, 2001 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
1054-139X/01/$–see front matter PII S1054-139X(01)00252-X
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Several studies have measured adolescents’ access to health care using the model of Aday and Andersen [9], analyzing access to care in the context of predisposing factors (such as age, gender, and race), enabling factors (such as insurance status and geographic location) and factors that reflect need (such as perceived health and activity limitations) [5,6]. These studies show several consistent results. Although the majority of adolescents studied had received care from a physician within the study year, many did not; the proportion not receiving medical care ranged from 20% to 34% [5,7,8,10]. Those analyses that examined dental care found similar results, with 21% to 31% not receiving a dental visit in the past year [5,10,11]. The association between use of medical and dental services and demographic characteristics, however, is less clear. Several studies showed higher likelihood of preventive service use among white adolescents [6 – 8], whereas others showed higher rates of use among Blacks [12] or Asian/Pacific Islanders [5]. In some of these studies, these associations were not significant once other factors were controlled for in multivariate analyses [5,6]. These analyses also show mixed results in the factors affecting utilization, with some emphasizing the role of enabling variables such as insurance status and having a usual source of care in promoting access to health care [5,7,13] and others finding that predisposing factors such as race and ethnicity were significantly associated with the use of care [6,7]. The previous research has a number of limitations. Those studies that have used national survey data have relied for the most part on parental reports of adolescents’ service use. This approach risks underreporting service use if parents are not fully informed about their children’s visits to health care providers, especially if adolescents have access to services from nontraditional settings such as schoolbased health centers or teen clinics. Other surveys that have used adolescent self-reports suffer from small sample sizes or were only conducted in a single community [5,12]. Still others based their analyses on the American Academy of Pediatrics recommendation that preventive visits for adolescents take place only once every 2 years [8]. (This recommendation was revised in 1995 and now concurs with those of HRSA’s Bright Futures guidelines [4] and the American Medical Association’s Guidelines for Adolescent Preventive Care [3], which recommend an annual preventive visit.) Finally, most studies look only at broad racial and ethnic groups, with
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several focusing only on Blacks, Whites, and Hispanics [6,7,12]. None of these studies addressed the role of immigration status or cultural factors in the use of health services by adolescents. Immigration status is a demographic variable that is likely to influence adolescents and children’s access to health insurance and health services [14 –17]. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 limits certain legal immigrants’ access to public benefits such as Food Stamps and Supplemental Security Income, excludes new immigrants from Medicaid eligibility for 5 years, and gives states the option of denying non-emergency Medicaid services to legal immigrants thereafter [18]. Even if children are themselves citizens, parents may not encourage them to use services or to enroll in programs for which they are eligible for fear of threatening their own immigration status. Thus, youth in immigrant families may not receive appropriate services or learn the importance of regular preventive health care early in life. The present study is based on adolescents’ selfreported use of medical and dental services and is based on an ethnically diverse, nationally representative sample.
Methods Study Design and Sample This study uses data from the National Longitudinal Study of Adolescent Health (Add Health), a nationally representative survey of adolescents’ health status and behaviors [19]. The complex clustered sampling design of Add Health used 80 high schools and 52 feeder schools (junior high schools whose graduates later attend one of the 80 high schools) to identify respondents. The Add Health data set comprises three main questionnaires. The in-school questionnaire was administered to students in grades 7 to 12 in 132 schools. All students enrolled in the 132 schools were also eligible to complete a more indepth in-home interview. The interview was administered to 20,745 adolescents and consisted of both interviewer-assisted questions, as well as audioCASI technology for more sensitive questions. Parents of adolescents who completed in the in-home interview were then asked to complete an interviewer-assisted questionnaire. The in-home parent questionnaire was completed by 17,670 parents, generally the mother. Wave I data were collected in 1994 and 1995 and Wave II data were collected in 1996 [19,20].
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The present study is based on a sample of this data set that was made available for public use. Records from the adolescent in-home interview (n ⫽ 6504) were matched with parent questionnaires from Wave I. The final sample includes weighted data from the 5644 adolescents in the public use data set whose parents also completed the parent questionnaire. Variables Used in the Study Adolescent and parent characteristics were grouped into three types according to the Aday and Andersen model [9]. Adolescent predisposing variables include gender, age, race/ethnicity, place of birth, and language spoken at home. Health insurance was considered to be an adolescent-enabling variable and adolescents’ perception of their health status was used as a need variable. Similarly, parent characteristics were grouped into predisposing (age, race/ ethnicity, place of birth, education, and marital status) and enabling variables (employment status and annual household income). Adolescent age groups were created to reflect those used by the American Medical Association in recommending use of preventive health care services. The race/ethnicity variable was created by combining two variables, one for race and for ethnicity. Respondents of mixed race, American Indians, and those who selected the “other” category were combined into one category owing to small numbers. Parents were asked to identify the kind of health insurance their children had and were allowed to select more than one response. The category for individual or group private coverage was combined with that of prepaid health plans, such as HMOs or CHAMPUS, as they likely reflect employer-sponsored health insurance. The categories for Medicaid and Medicare were also combined, leaving four discrete categories: public, private, none, and other. All parent demographics refer to the parent who responded to the in-home questionnaire. In 93.4% of the cases, the adolescent’s mother was interviewed. Many education response categories were collapsed into one indicating that the parent had gone on to receive some type of education after high school, including business, trade, and vocational schools, as well as college and additional professional training. Parents were asked to report their total gross household income from all sources in 1994. The current study analyzed four dependent variables. Adolescents were asked: “When did you last
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have a physical examination by a doctor or nurse?” One dichotomous variable was created to compare adolescents who had not been to the doctor within one year (as recommended by the American Medical Association) to those who had. A second dichotomous variable was created to compare adolescents who had never had a physical examination with those who had. Respondents were also asked, “When did you last have a dental examination by a dentist or hygienist.” Two dichotomous variables were also created for use of preventive dental health services, one for those who had not been to the dentist in the last year and one for those who had never had a dental examination.
Statistical Analysis We began the analysis by summarizing the characteristics of the study sample, followed by bivariate analysis of the demographic variables with each of the four dependent variables. Variables that were significant at the .05 level were included in the initial logistic regression models for each of the four outcomes. In instances in which both adolescents’ race/ ethnicity and parents’ race/ethnicity were significant in the bivariate analyses, we entered the adolescents’ race/ethnicity into the model. A series of diagnostic tests for multicollinearity were conducted in SAS, based on accepted approaches [21]. The condition indices did not indicate multicollinearity, and both tolerance and the variance inflation indices approximate 1. The data set was created and variables of interest recoded using SAS. Bivariate and logistic regression analyses were conducted using SUDAAN version 7.11, a software package developed by the Research Triangle Institute (Research Triangle Park, NC) for the statistical analysis of data generated from complex clustered sampling designs. The Wald Fstatistic was used to determine the significance of the model components. Adjusted odds ratios, 95% confidence intervals, and the p values are reported for all variables in the models.
Results Demographic Characteristics The sample includes 5644 adolescent–parent dyads. Table 1 describes the demographic characteristics of the adolescents in the sample and their parents. This table displays the distributions of the unweighted sample size for each variable, along with the corresponding weighted percent distributions. Table 1
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Table 1. Adolescent and Parenta Demographic Variables and Adolescents’ Use of Preventive Health Services Adolescent Independent Variables Adolescent predisposing variables Gender Male Female Age (years) 11 to 14 15 to 17 18 to 21 Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Place of birth United States Another country Language spoken at home English Spanish Other Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare None Other Adolescent need variables Perception of health status Excellent Very good Good Fair Poor
Unweighted Nb N ⫽ 5644
Weighted percentc
2749 2895
51.1 48.9
1840 2995 807
35.7 50.0 14.3
3330 1216 619 310 147
67.1 14.2 11.8 4.7 2.3
4190 301
93.2 8.8
5306 245 91
93.8 4.7 1.5
4084 588 641 243
73.1 10.9 11.8 4.1
Table 1. (Continued) Adolescent Independent Variables Age (years) 45 to 49 50⫹ Race/Ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Place of birth United States Another country Education Less than High School High School or GED More than high school Marital status Married Not married Parent enabling variables Works outside the home Yes No Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more
Unweighted Nb N ⫽ 5644
Weighted percentc
1147 528
19.5 9.2
3475 1207 541 196 158
69.7 14.3 10.4 3.2 2.4
4991 633
89.0 11.0
860 1692 3055
16.3 32.3 51.4
3955 1683
71.7 28.3
4149 1476
72.6 27.4
1031 1413 1169 1302
21.4 28.6 24.3 25.8
a
Refers to parent that responded to questionnaire. May not sum to total sample size owing to missing data. c May not sum to 100% owing to rounding. b
1605 2280 1389 341 24
Dependent variables Last physical examination by doctor or nurse Less than 12 months 3882 1 to 2 years ago 1175 More than 2 years ago 439 Never 119 Last dental examination by dentist or hygienist Less than 12 months 3806 1 to 2 years ago 1079 More than 2 years ago 601 Never 135 Thought should get medical care in last year, but did not get No 4593 Yes 1043 Parent independent variables Parent predisposing variables Age (years) 34 or younger 619 35 to 39 1606 40 to 44 1704
27.8 40.3 25.1 6.3 0.5
68.0 21.4 8.4 2.2
68.3 19.0 10.3 2.4
82.2 17.8
11.4 29.4 30.6 (Continued)
shows that most survey respondents were adolescents between the ages of 15 and 17 years, white, born in the United States and speak English at home. The sample was evenly divided between males and females. Most respondents have some form of private insurance and perceive their health status to be either excellent or good. However, 641 respondents, representing roughly 2.3 million adolescents nationwide, did not have any health insurance. According to the survey, an additional 1.3 million adolescents consider themselves to be in fair or poor health. We see as well that most parents responding to the survey were in their late thirties or early forties, were white, born in the United States, had achieved more than a high school education, and were married. Most parents work outside the home, and income was fairly equally divided among the four income categories (thus overrepresenting higher-income families, as compared with the national income distribution).
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Adolescents’ Use of Preventive Medical and Dental Health Services Table 1 also shows the distribution of the dependent variables. Most adolescents had received a physical examination in the last 12 months; few had never had a physical examination (2.2%). However, weighted estimates show this proportion to represent roughly 436,000 adolescents nationwide. Results were similar for use of preventive dental health services. Roughly 68% of adolescents in the sample had a dental examination in the past year, whereas 2.4% had never had an examination. Weighted estimates show this proportion to represent 466,000 adolescents nationwide.
Bivariate Analyses Table 2 displays the results of the bivariate analysis for the two medical outcomes and Table 3 provides results for the two dental outcomes. The same 14 independent variables displayed in Table 1 were analyzed with each of the outcome variables. As displayed in Table 2, adolescents who are Hispanic, Asian/Pacific Islander, and of mixed race are significantly more likely not to have had a medical examination in the past year, as are those without health insurance and those who rate their health as “good” or “fair”. Having parents who are not black or white, parents with a high school education or less, and low household income are also associated with not receiving an annual medical examination. The proportion of adolescents who have never had a medical examination is small in all categories; however, those who rate their health as “very good,” “good,” or “fair” are more likely to fall into this category. Low levels of parental education and low household income are also positively associated with a lack of preventive care. For example, 4.2% of adolescents whose parents have less than a high school education have never had a medical examination, compared with 1.3% of those with parents who have gone beyond high school. Table 3 shows the results of similar analyses of the use of dental care. Overall, 31.7% of teens reported not having had a dental visit in the past year. The lack of an annual dental visit is associated with gender (33.6% of males vs. 29.8% of females), age (37.2% of teens 18 –21 years compared with 29.3% of those 11–14), race/ethnicity (44.9% of Hispanics vs. 26.6% of Whites), and language spoken at home (48.5% of Spanish-speakers compared with 30.8% of English-speakers). In addition, health insurance is
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associated with use of dental services: more than half of uninsured teens did not have an annual dental examination, compared with 25.9% with insurance. As with medical care, those with good or fair perceived health status were most likely not to receive preventive dental care. Lack of an annual dental visit was also associated with several parental variables, including age (with those with the youngest and oldest parents least likely to receive services), race/ ethnicity, place of birth, education, marital status, employment, and income. A much smaller proportion (2.4%) of respondents had never had a dental examination. Those who were black or Hispanic, born outside the United States, or uninsured were most likely to fall into this category. A complete lack of dental care was also associated with parental age, race/ethnicity, place of birth, education, employment, and income. The greatest likelihood of never having had a dental examination was seen among Hispanics and children of immigrant parents: e.g., 5.3% of children of immigrants, compared with 2.1% of children of parents born in the United States, had never received dental care. Logistic Regression Analyses Table 4 displays results from the two logistic regression models exploring adolescents’ use of preventive medical services. Having no insurance and having a family income of $20,000 – $39,999 were significantly associated with the lack of a medical visit in the past year (Table 4, Model 1). Respondents who rated their health as “excellent” or “very good” were slightly less likely (OR ⫽ .78, 95% CI 0.65, 0.94) to have gone without a medical examination. In contrast, never having had a medical examination was associated only with variables describing the parent: having only a high school diploma or GED (OR ⫽ 1.88, 95% CI 1.06, 3.33) and having a fairly low income ($20,000 –$39,999, OR ⫽ 2.59, 95% CI 1.06, 6.30) were associated with the lack of medical examinations (Table 4, Model 2). Not having a dental examination in the last year was associated with predisposing, enabling, and need variables (Table 5, Model 3). The respondents’ gender, race/ethnicity, and age were all significantly associated with a lack of an annual dental visit, with males, older teens, and non-Whites (particularly Blacks) more likely not to receive care. Uninsured teens were more than twice as likely not to receive a dental visit (OR ⫽ 2.23, 95% CI 1.68, 2.95). Again, those in the best health were significantly less likely to go without care (OR ⫽ 0.83, 95% CI 0.70, 0.98).
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Table 2. Use of Medical Services by selected Adolescent and Parent Characteristics No Medical Exam. in Last 12 Months (32%) Characteristic Adolescent predisposing variables Age (years) 11 to 14 15 to 17 18 to 21 Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health status Excellent Very good Good Fair Poor Parent predisposing variables Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian Education Less than high school High school or GED More than high school Marital status Married Not married Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more a
(%)
p valuea
Never Had a Medical Exam. (2.2%) (%)
.08 30.0 32.8 34.5
.57 2.4 2.0 2.7
.03 31.0 31.0 35.6 36.1 40.9
.21 1.9 1.9 3.3 5.1 2.5
.00 30.6 26.5 31.7 45.6
.06 1.8 1.5 2.5 5.7
.00 26.0 32.4 36.8 39.0 19.5
.02 1.7 2.4 2.5 3.0 0.0
.00 30.8 31.0 37.2 37.1 42.9
.49 1.9 2.1 3.7 4.7 2.4
.00 36.0 34.7 29.3
.00 4.2 2.7 1.3
.24 31.6 33.2
.37 2.4 1.9
.00 32.4 36.9 30.0 27.5
p value
.01 2.3 3.2 1.9 1.0
Chi-square test.
Those whose parents had low levels of education and income, as well as those who did not work outside the home, were also more likely to forgo an annual dental visit. Never having had dental care was associated only with adolescent demographic (predisposing) charac-
teristics and parental economic (enabling) characteristics (Table 5, Model 4). Respondents born outside the United States were more than twice as likely as native-born teens to go without dental care (OR ⫽ 2.38, 95% CI 1.24, 4.59). Black and Hispanic respondents were also more than twice as likely as Whites
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Table 3. Dental Services by Selected Adolescent and Parent Characteristics No Dental Exam. in Last 12 Months (31.7%) Characteristic Adolescent predisposing variables Gender Male Female Age (years) 11 to 14 15 to 17 18 to 21 Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Place of birth United States Another country Language spoken at home English Spanish Other Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health status Excellent Very good Good Fair Poor Parent predisposing variables Age (years) 34 or younger 35 to 39 40 to 44 45 to 49 50⫹ Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian Place of birth United States Another country Education Less than high school High school or GED More than high school
(%)
p valuea
Never Had a Dental Exam. (2.4%) (%)
.02 33.6 29.8
.68 2.5 2.3
.00 29.3 32.0 37.2
.60 2.7 2.3 2.0
.00 26.6 43.7 44.9 36.8 30.1
.00 1.4 4.7 5.7 1.2 2.2
.17 32.8 39.5
.03 2.2 7.2
.02 30.8 48.5 39.8
.08 2.1 8.5 4.2
.00 25.9 39.9 37.4 57.0
.00 1.6 3.6 1.7 6.7
.00 26.3 30.6 36.8 42.9 30.3
.73 2.4 2.1 2.6 3.5 4.7
.00 37.1 33.2 29.0 28.1 36.7
.01 2.4 3.5 1.9 1.3 3.0
.00 27.1 43.9 44.0 43.8 30.2
.00 1.4 4.8 6.1 2.2 2.5
.03 30.9 38.9
.03 2.1 5.3
.00 47.6 33.3 25.8
p value
.00 5.8 2.9 1.1 (Continued)
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Table 3. (Continued) No Dental Exam. in Last 12 Months (31.7%) Characteristic
(%)
Parent predisposing variables (con’t) Marital status Married Not married
28.6 39.6
Parent enabling variables Works outside the home Yes No Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more a
Never Had a Dental Exam. (2.4%)
p valuea
(%)
.00
p value .16
2.2 2.9
.00
.00
29.6 37.7
1.7 4.3 .00
.00
43.7 38.7 29.2 16.7
4.7 3.8 1.1 0.3
Chi-square test.
Table 4. Multivariate Analysis Examining Adolescents’ Use of Medical Services Characteristic Model 1: No medical visit in last year Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health Excellent/very good Good Fair/poor Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more Model 2: Never had medical examination Parent predisposing variables Education Less than high school High school or GED More than high school Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more a
Reference group
Adjusted OR
95% CI
p value
***a 0.87 0.99 1.82
(0.68, 1.10) (0.70, 1.39) (1.47, 2.25)
.24 .94 .00
(0.65, 0.94)
.01
(0.76, 1.37)
.90
1.11 1.41 1.12 ***
(0.87, 1.42) (1.16, 1.72) (0.91, 1.38)
.38 .00 .27
1.96 1.88 ***
(0.98, 3.92) (1.06, 3.33)
.06 .03
1.66 2.59 1.64 ***
(0.62, 4.46) (1.06, 6.30) (0.57, 4.68)
.31 .04 .35
0.78 *** 1.02
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Table 5. Multivariate Analysis Examining Adolescents’ Use of Dental Services Characteristic Model 3: No dental examination in last year Adolescent Predisposing Variables Gender Male Female Age (years) 11 to 14 15 to 17 18 to 21 Race/Ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed Heritage & Other Asian/Pacific Islander Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health Excellent/very good Good Fair/poor Parent predisposing variables Education Less than high school High school or GED More than high school Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more Works outside the home Yes No Model 4: Never had a dental examination Adolescent predisposing variables Place of birth United States Another country Race/Ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more Works outside the home Yes No a
Reference group
Adj. OR
1.2 ***a
95% CI
p value
(1.02, 1.41)
.03
*** 1.18 1.46
(1.01, 1.37) (1.18, 1.80)
.04 .00
*** 1.70 1.46 1.44 1.08
(1.34, 2.16) (1.15, 1.84) (1.07, 1.94) (0.64, 1.82)
.00 .00 .02 .76
*** 1.16 1.42 2.23
(0.89, 1.50) (0.98, 2.06) (1.68, 2.95)
.26 .06 .00
(0.70, 0.98)
.03
(0.84, 1.56)
.38
1.44 1.07 ***
(1.13, 1.84) (0.90, 1.27)
.00 .42
2.16 2.39 1.94 ***
(1.58, 2.94) (1.89, 3.03) (1.50, 2.51)
.00 .00 .00
*** 1.23
(1.01, 1.50)
.04
*** 2.38
(1.24, 4.59)
.01
*** 2.72 2.27 0.74 0.49
(1.43, 5.16) (1.12, 4.63) (0.13, 4.38) (0.06, 4.10)
.00 .02 .74 .50
(1.99, 21.65) (2.28, 26.73) (0.78, 10.00)
.00 .00 0.11
(1.17, 3.67)
.01
0.83 *** 1.15
6.56 7.81 2.79 *** *** 2.07
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never to have seen a dentist. Those whose parents reported incomes in the two lowest categories were 6 –7 times as likely (compared with those in highincome families) never to have received dental care.
Discussion Our multivariate analyses show that most demographic characteristics, including race/ethnicity, place of birth, and language spoken at home, are not significantly related to adolescents’ use of preventive medical care. In fact, the only significant predisposing variables related to teens’ use of preventive medical care was parents’ education, and the only significant enabling variables were insurance status and household income. The relationship between health insurance and access to medical (and dental) care is not surprising. This finding is enhanced, however, by additional information about the relationship between household income and access to preventive care: adolescents with family incomes in the low to middle range ($20,000 –$39,000) were significantly more likely than those in high-income families (with incomes of $60,000 or more) not to have had a medical or dental examination in the past year or never to have had a medical examination. (In the case of dental care, any income level below $60,000 was significantly associated with a lack of care, but the odds ratio was highest for the low-middle income group.) Thus, it would appear that those in the lowest income category, who are likely to be eligible for Medicaid, are less likely to experience access barriers than those with slightly higher incomes. (Unfortunately, the survey did not include information about family size, so it was not possible to analyze income in relationship to the federal poverty level.) After controlling for other variables, adolescents’ and their parents’ place of birth was not significantly associated with the use of medical services. However, adolescents born outside the United States were significantly more likely never to have had a dental examination. Indeed, these findings demonstrate the breadth of need for dental care, particularly among traditionally underserved populations and children of immigrant families. Nearly half of respondents who speak Spanish at home, 44% of those with low family incomes, and 48% of those whose parents have less than a high school education did not receive a dental examination in the past year. Uninsured teens were also twice as likely as those with private insurance not to have received a dental
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checkup. Even among Medicaid recipients, who are theoretically entitled to dental benefits, nearly 40% had no dental visit in the year before the survey. It appears that the use of dental care is vulnerable to any of a number of factors; although the overall proportion of respondents who did not receive an annual dental visit did not differ greatly from the proportion that did not receive a medical examination, barriers to the use of dental services abound, including educational barriers, language barriers, economic barriers, and a lack of available providers for those enrolled in Medicaid [22,23]. Two potential limitations of this study should be noted. First, the data on adolescents’ use of health services are self-reported. Adolescents’ reports of health care utilization were not confirmed with medical records. Second, the Add Health sample was drawn using schools. As a result, adolescents who are not enrolled in school were excluded from this study. This population may include high-risk youth who have dropped out of school or those with chronic or disabling conditions. Therefore, the study results will not apply to adolescents who are not enrolled in school. These findings are particularly timely as states implement Medicaid expansions and separate state health insurance programs under the State Child Health Insurance Program (SCHIP) authorized under the Balanced Budget Act of 1997. A large proportion of children eligible for these programs are likely to be adolescents, as Medicaid’s previous income eligibility standards were stricter for adolescents than for younger children. These findings demonstrate the need to promote the importance of preventive medical and dental care to previously uninsured teens, many of whom may be unaccustomed to regular well-child visits. Particularly in the case of dental care, those children who make up the majority of SCHIP eligibles, Hispanic children of low-income working parents, are the most likely to have gone without care in the past and to demonstrate pent-up demand for services. Moreover, children in immigrant families, who may be reluctant to enroll in SCHIP for legal reasons, will require targeted outreach to assure that they are able to use the services for which they are now eligible.
References 1. Monheit AC, Cunningham PJ. Children without health insurance. Future Child 1992;2:154 –70. 2. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Recommendations for Preventive Pe-
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diatric Health Care. Elk Grove Village, IL: American Academy of Pediatrics, 2000. American Medical Association. Guidelines for Adolescent Preventive Services: Recommendations Monograph. Chicago: American Medical Association, 1995. Green M, Palfrey JS (eds). Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Second Edition. Arlington, VA: National Center for Education in Maternal and Child Health, 2000. Ryan SA, Millstein SG, Greene B, Irwin CE. Utilization of ambulatory health services by urban adolescents. J Adolesc Health 1996;18:192–202. Lieu TA, Newacheck PW, McManus MA. Race, ethnicity, and access to ambulatory care among US adolescents. Am J Public Health 1993;83:960 –5. Bartman BA, Moy E, D’Angelo LJ. Access to ambulatory care for adolescents: The role of a usual source of care. J Health Care Poor Underserved 1997;8:214 –26. Zimmer-Gembeck MJ, Alexander T, Nustron RJ. Adolescents report their need for and use of health care services. J Adolesc Health 1997;21:388 –99. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res 1974;9:208 –20. Newacheck PA, Brindis CD, Cart CU, et al. Adolescent health insurance coverage: recent changes and access to care. Pediatrics 1999;104:195–202. Kenney GM, Ko G, Ormond B. Gaps in Prevention and Treatment: Dental Care for Low-Income Children. Issue Brief Number B-15. Washington, DC: The Urban Institute, 2000. Aten MJ, Siegel DM, Roghmann, KJ. Use of health services by urban youth: a school-based survey to assess differences by grade level, gender, and risk behavior. J Adolesc Health 1996;19:258 – 66.
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13. Ford CA, Bearman PS, Moody J. Foregone health care among adolescents. JAMA 1999;282:2227–34. 14. Thamer M, Richard C, Casebeer AW, Ray NF. Health insurance coverage among foreign-born US residents: the impact of race, ethnicity, and length of residence. Am J Public Health 1997;87:96 –102. 15. Sun WY, Sangweni B, Butts G, Merlino M. Comparisons of immunisation accessibility between non–US born and USborn children in New York City. Public Health 1998;112:405– 8. 16. Rew L, Resnick M, Buehring T. Usual sources, patterns of utilization, and foregone health care among Hispanic adolescents. J Adolesc Health 1999:25:407–13. 17. Sonis J. Association between duration of residence and access to ambulatory care among Caribbean immigrant adolescents. Am J Public Health 1998;88:964 – 6. 18. Personal Responsibility and Work Opportunity Reconciliation Act, P.L. 104 –193, 1996. 19. The National Longitudinal Study of Adolescent Health. The Add Health Study, Research Design. Available at: http:// www.cpc.unc.edu/addhealth/design.html. 20. Chantala, K, Tabor J. Strategies to Perform a Design-Based Analysis Using the Add Health Data. Chapel Hill, NC: Carolina Population Center, University of North Carolina at Chapel Hill; June 1999. 21. Belsley DA, Kuh E, Welsh RE. Regression diagnostics: Identifying influential data and sources of collinearity. New York: John Wiley and Sons, 1980. 22. Milgrom P, Mancl L, King B, et al. An explanatory model of the dental care utilization of low–income children. Medical Care 1998;36:554 – 66. 23. Edelstein BL, Maski RK, Moeller JF. Pediatric dental visits during 1996: An analysis of the federal Medical Expenditure Panel Survey. Pediatric Dent 2000;22:17–20.
ORIGINAL ARTICLE
Factors Associated With Use of Preventive Dental and Health Services Among U.S. Adolescents STELLA M. YU, Sc.D., M.P.H., HILARY A. BELLAMY, M.P.H., RENEE H. SCHWALBERG, M.P.H., AND M. ANN DRUM, D.D.S., M.P.H.
Purpose: To examine adolescents’ use of preventive medical and dental services and its relationship to demographic characteristics and other variables reflecting access to and need for care. Methods: Self- and parent-reported data from a sample of 5644 adolescents aged 11 to 21 years from the National Longitudinal Study of Adolescent Health (Add Health). Variables studied include the influence of both the adolescents’ demographic and socioeconomic characteristics (age, race/ethnicity, place of birth, acculturation, insurance status, and perception of health), as well as those of their parents (race/ethnicity, income, level of education, place of birth) on their lifetime use and use within the past year of medical and dental services. Bivariate and logistic regression analyses were conducted using SAS and SUDAAN. Results: Approximately 32% of respondents had not had a physical examination in the year before the survey, and the same percentage had not had a dental examination. Approximately 2% reported never having had either a physical or a dental examination. Logistic regression reveals that lack of insurance, low family income, and low parental education level are significantly associated with the lack of preventive medical care. Lack of an annual dental visit was associated with male gender; black, Hispanic, or mixed race/ethnicity; and lack of insurance. Never having had a dental visit was the only
From the Maternal and Child Health Bureau, Office of Data and Information Management, Rockville, Maryland (S.M.Y., M.A.D.); and the Maternal and Child Health Information Resource Center, Washington, D.C. (H.A.B., R.H.S.). Address correspondence to: Stella Yu, Sc.D., M.P.H., Maternal and Child Health Bureau, Office of Data and Information Management, 5600 Fishers Lane, 18A-55, Rockville, MD 20857. The opinions expressed in this paper are the authors’ and do not necessarily reflect the views or policies of the institutions with which the authors are affiliated. Manuscript accepted March 29, 2001.
dependent variable found to be associated with place of birth. Conclusions: Health insurance and family income are most consistently related to adolescents’ use of preventive medical and dental care. However, the relationship between lack of dental care and place of birth emphasizes the need to improve access to dental services for immigrant teens. These findings are particularly relevant as states design systems of care for adolescents under the State Children’s Health Insurance Program. © Society for Adolescent Medicine, 2001 KEY WORDS:
Adolescents Prevention Dental care Immigrants
Adolescents are among those least likely to use health services [1]. The American Academy of Pediatrics, the American Medical Association, and the Health Resources and Services Administration’s Bright Futures Guidelines for Infants, Children and Adolescents recommend a routine preventive visit each year for adolescents from ages 11 through 21 years [2– 4]. However, research [5– 8] suggests that a substantial proportion of adolescents do not receive care with this frequency. This may be owing to factors related to the acceptability of the services themselves, to confidentiality and sensitivity to adolescents’ health concerns, or to lack of access to care for financial or geographic reasons. Moreover, adolescents’ access to preventive medical and dental care and treatment services may vary by their race, ethnicity, age, family income, and insurance status.
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Several studies have measured adolescents’ access to health care using the model of Aday and Andersen [9], analyzing access to care in the context of predisposing factors (such as age, gender, and race), enabling factors (such as insurance status and geographic location) and factors that reflect need (such as perceived health and activity limitations) [5,6]. These studies show several consistent results. Although the majority of adolescents studied had received care from a physician within the study year, many did not; the proportion not receiving medical care ranged from 20% to 34% [5,7,8,10]. Those analyses that examined dental care found similar results, with 21% to 31% not receiving a dental visit in the past year [5,10,11]. The association between use of medical and dental services and demographic characteristics, however, is less clear. Several studies showed higher likelihood of preventive service use among white adolescents [6 – 8], whereas others showed higher rates of use among Blacks [12] or Asian/Pacific Islanders [5]. In some of these studies, these associations were not significant once other factors were controlled for in multivariate analyses [5,6]. These analyses also show mixed results in the factors affecting utilization, with some emphasizing the role of enabling variables such as insurance status and having a usual source of care in promoting access to health care [5,7,13] and others finding that predisposing factors such as race and ethnicity were significantly associated with the use of care [6,7]. The previous research has a number of limitations. Those studies that have used national survey data have relied for the most part on parental reports of adolescents’ service use. This approach risks underreporting service use if parents are not fully informed about their children’s visits to health care providers, especially if adolescents have access to services from nontraditional settings such as schoolbased health centers or teen clinics. Other surveys that have used adolescent self-reports suffer from small sample sizes or were only conducted in a single community [5,12]. Still others based their analyses on the American Academy of Pediatrics recommendation that preventive visits for adolescents take place only once every 2 years [8]. (This recommendation was revised in 1995 and now concurs with those of HRSA’s Bright Futures guidelines [4] and the American Medical Association’s Guidelines for Adolescent Preventive Care [3], which recommend an annual preventive visit.) Finally, most studies look only at broad racial and ethnic groups, with
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several focusing only on Blacks, Whites, and Hispanics [6,7,12]. None of these studies addressed the role of immigration status or cultural factors in the use of health services by adolescents. Immigration status is a demographic variable that is likely to influence adolescents and children’s access to health insurance and health services [14 –17]. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 limits certain legal immigrants’ access to public benefits such as Food Stamps and Supplemental Security Income, excludes new immigrants from Medicaid eligibility for 5 years, and gives states the option of denying non-emergency Medicaid services to legal immigrants thereafter [18]. Even if children are themselves citizens, parents may not encourage them to use services or to enroll in programs for which they are eligible for fear of threatening their own immigration status. Thus, youth in immigrant families may not receive appropriate services or learn the importance of regular preventive health care early in life. The present study is based on adolescents’ selfreported use of medical and dental services and is based on an ethnically diverse, nationally representative sample.
Methods Study Design and Sample This study uses data from the National Longitudinal Study of Adolescent Health (Add Health), a nationally representative survey of adolescents’ health status and behaviors [19]. The complex clustered sampling design of Add Health used 80 high schools and 52 feeder schools (junior high schools whose graduates later attend one of the 80 high schools) to identify respondents. The Add Health data set comprises three main questionnaires. The in-school questionnaire was administered to students in grades 7 to 12 in 132 schools. All students enrolled in the 132 schools were also eligible to complete a more indepth in-home interview. The interview was administered to 20,745 adolescents and consisted of both interviewer-assisted questions, as well as audioCASI technology for more sensitive questions. Parents of adolescents who completed in the in-home interview were then asked to complete an interviewer-assisted questionnaire. The in-home parent questionnaire was completed by 17,670 parents, generally the mother. Wave I data were collected in 1994 and 1995 and Wave II data were collected in 1996 [19,20].
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The present study is based on a sample of this data set that was made available for public use. Records from the adolescent in-home interview (n ⫽ 6504) were matched with parent questionnaires from Wave I. The final sample includes weighted data from the 5644 adolescents in the public use data set whose parents also completed the parent questionnaire. Variables Used in the Study Adolescent and parent characteristics were grouped into three types according to the Aday and Andersen model [9]. Adolescent predisposing variables include gender, age, race/ethnicity, place of birth, and language spoken at home. Health insurance was considered to be an adolescent-enabling variable and adolescents’ perception of their health status was used as a need variable. Similarly, parent characteristics were grouped into predisposing (age, race/ ethnicity, place of birth, education, and marital status) and enabling variables (employment status and annual household income). Adolescent age groups were created to reflect those used by the American Medical Association in recommending use of preventive health care services. The race/ethnicity variable was created by combining two variables, one for race and for ethnicity. Respondents of mixed race, American Indians, and those who selected the “other” category were combined into one category owing to small numbers. Parents were asked to identify the kind of health insurance their children had and were allowed to select more than one response. The category for individual or group private coverage was combined with that of prepaid health plans, such as HMOs or CHAMPUS, as they likely reflect employer-sponsored health insurance. The categories for Medicaid and Medicare were also combined, leaving four discrete categories: public, private, none, and other. All parent demographics refer to the parent who responded to the in-home questionnaire. In 93.4% of the cases, the adolescent’s mother was interviewed. Many education response categories were collapsed into one indicating that the parent had gone on to receive some type of education after high school, including business, trade, and vocational schools, as well as college and additional professional training. Parents were asked to report their total gross household income from all sources in 1994. The current study analyzed four dependent variables. Adolescents were asked: “When did you last
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have a physical examination by a doctor or nurse?” One dichotomous variable was created to compare adolescents who had not been to the doctor within one year (as recommended by the American Medical Association) to those who had. A second dichotomous variable was created to compare adolescents who had never had a physical examination with those who had. Respondents were also asked, “When did you last have a dental examination by a dentist or hygienist.” Two dichotomous variables were also created for use of preventive dental health services, one for those who had not been to the dentist in the last year and one for those who had never had a dental examination.
Statistical Analysis We began the analysis by summarizing the characteristics of the study sample, followed by bivariate analysis of the demographic variables with each of the four dependent variables. Variables that were significant at the .05 level were included in the initial logistic regression models for each of the four outcomes. In instances in which both adolescents’ race/ ethnicity and parents’ race/ethnicity were significant in the bivariate analyses, we entered the adolescents’ race/ethnicity into the model. A series of diagnostic tests for multicollinearity were conducted in SAS, based on accepted approaches [21]. The condition indices did not indicate multicollinearity, and both tolerance and the variance inflation indices approximate 1. The data set was created and variables of interest recoded using SAS. Bivariate and logistic regression analyses were conducted using SUDAAN version 7.11, a software package developed by the Research Triangle Institute (Research Triangle Park, NC) for the statistical analysis of data generated from complex clustered sampling designs. The Wald Fstatistic was used to determine the significance of the model components. Adjusted odds ratios, 95% confidence intervals, and the p values are reported for all variables in the models.
Results Demographic Characteristics The sample includes 5644 adolescent–parent dyads. Table 1 describes the demographic characteristics of the adolescents in the sample and their parents. This table displays the distributions of the unweighted sample size for each variable, along with the corresponding weighted percent distributions. Table 1
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Table 1. Adolescent and Parenta Demographic Variables and Adolescents’ Use of Preventive Health Services Adolescent Independent Variables Adolescent predisposing variables Gender Male Female Age (years) 11 to 14 15 to 17 18 to 21 Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Place of birth United States Another country Language spoken at home English Spanish Other Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare None Other Adolescent need variables Perception of health status Excellent Very good Good Fair Poor
Unweighted Nb N ⫽ 5644
Weighted percentc
2749 2895
51.1 48.9
1840 2995 807
35.7 50.0 14.3
3330 1216 619 310 147
67.1 14.2 11.8 4.7 2.3
4190 301
93.2 8.8
5306 245 91
93.8 4.7 1.5
4084 588 641 243
73.1 10.9 11.8 4.1
Table 1. (Continued) Adolescent Independent Variables Age (years) 45 to 49 50⫹ Race/Ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Place of birth United States Another country Education Less than High School High School or GED More than high school Marital status Married Not married Parent enabling variables Works outside the home Yes No Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more
Unweighted Nb N ⫽ 5644
Weighted percentc
1147 528
19.5 9.2
3475 1207 541 196 158
69.7 14.3 10.4 3.2 2.4
4991 633
89.0 11.0
860 1692 3055
16.3 32.3 51.4
3955 1683
71.7 28.3
4149 1476
72.6 27.4
1031 1413 1169 1302
21.4 28.6 24.3 25.8
a
Refers to parent that responded to questionnaire. May not sum to total sample size owing to missing data. c May not sum to 100% owing to rounding. b
1605 2280 1389 341 24
Dependent variables Last physical examination by doctor or nurse Less than 12 months 3882 1 to 2 years ago 1175 More than 2 years ago 439 Never 119 Last dental examination by dentist or hygienist Less than 12 months 3806 1 to 2 years ago 1079 More than 2 years ago 601 Never 135 Thought should get medical care in last year, but did not get No 4593 Yes 1043 Parent independent variables Parent predisposing variables Age (years) 34 or younger 619 35 to 39 1606 40 to 44 1704
27.8 40.3 25.1 6.3 0.5
68.0 21.4 8.4 2.2
68.3 19.0 10.3 2.4
82.2 17.8
11.4 29.4 30.6 (Continued)
shows that most survey respondents were adolescents between the ages of 15 and 17 years, white, born in the United States and speak English at home. The sample was evenly divided between males and females. Most respondents have some form of private insurance and perceive their health status to be either excellent or good. However, 641 respondents, representing roughly 2.3 million adolescents nationwide, did not have any health insurance. According to the survey, an additional 1.3 million adolescents consider themselves to be in fair or poor health. We see as well that most parents responding to the survey were in their late thirties or early forties, were white, born in the United States, had achieved more than a high school education, and were married. Most parents work outside the home, and income was fairly equally divided among the four income categories (thus overrepresenting higher-income families, as compared with the national income distribution).
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Adolescents’ Use of Preventive Medical and Dental Health Services Table 1 also shows the distribution of the dependent variables. Most adolescents had received a physical examination in the last 12 months; few had never had a physical examination (2.2%). However, weighted estimates show this proportion to represent roughly 436,000 adolescents nationwide. Results were similar for use of preventive dental health services. Roughly 68% of adolescents in the sample had a dental examination in the past year, whereas 2.4% had never had an examination. Weighted estimates show this proportion to represent 466,000 adolescents nationwide.
Bivariate Analyses Table 2 displays the results of the bivariate analysis for the two medical outcomes and Table 3 provides results for the two dental outcomes. The same 14 independent variables displayed in Table 1 were analyzed with each of the outcome variables. As displayed in Table 2, adolescents who are Hispanic, Asian/Pacific Islander, and of mixed race are significantly more likely not to have had a medical examination in the past year, as are those without health insurance and those who rate their health as “good” or “fair”. Having parents who are not black or white, parents with a high school education or less, and low household income are also associated with not receiving an annual medical examination. The proportion of adolescents who have never had a medical examination is small in all categories; however, those who rate their health as “very good,” “good,” or “fair” are more likely to fall into this category. Low levels of parental education and low household income are also positively associated with a lack of preventive care. For example, 4.2% of adolescents whose parents have less than a high school education have never had a medical examination, compared with 1.3% of those with parents who have gone beyond high school. Table 3 shows the results of similar analyses of the use of dental care. Overall, 31.7% of teens reported not having had a dental visit in the past year. The lack of an annual dental visit is associated with gender (33.6% of males vs. 29.8% of females), age (37.2% of teens 18 –21 years compared with 29.3% of those 11–14), race/ethnicity (44.9% of Hispanics vs. 26.6% of Whites), and language spoken at home (48.5% of Spanish-speakers compared with 30.8% of English-speakers). In addition, health insurance is
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associated with use of dental services: more than half of uninsured teens did not have an annual dental examination, compared with 25.9% with insurance. As with medical care, those with good or fair perceived health status were most likely not to receive preventive dental care. Lack of an annual dental visit was also associated with several parental variables, including age (with those with the youngest and oldest parents least likely to receive services), race/ ethnicity, place of birth, education, marital status, employment, and income. A much smaller proportion (2.4%) of respondents had never had a dental examination. Those who were black or Hispanic, born outside the United States, or uninsured were most likely to fall into this category. A complete lack of dental care was also associated with parental age, race/ethnicity, place of birth, education, employment, and income. The greatest likelihood of never having had a dental examination was seen among Hispanics and children of immigrant parents: e.g., 5.3% of children of immigrants, compared with 2.1% of children of parents born in the United States, had never received dental care. Logistic Regression Analyses Table 4 displays results from the two logistic regression models exploring adolescents’ use of preventive medical services. Having no insurance and having a family income of $20,000 – $39,999 were significantly associated with the lack of a medical visit in the past year (Table 4, Model 1). Respondents who rated their health as “excellent” or “very good” were slightly less likely (OR ⫽ .78, 95% CI 0.65, 0.94) to have gone without a medical examination. In contrast, never having had a medical examination was associated only with variables describing the parent: having only a high school diploma or GED (OR ⫽ 1.88, 95% CI 1.06, 3.33) and having a fairly low income ($20,000 –$39,999, OR ⫽ 2.59, 95% CI 1.06, 6.30) were associated with the lack of medical examinations (Table 4, Model 2). Not having a dental examination in the last year was associated with predisposing, enabling, and need variables (Table 5, Model 3). The respondents’ gender, race/ethnicity, and age were all significantly associated with a lack of an annual dental visit, with males, older teens, and non-Whites (particularly Blacks) more likely not to receive care. Uninsured teens were more than twice as likely not to receive a dental visit (OR ⫽ 2.23, 95% CI 1.68, 2.95). Again, those in the best health were significantly less likely to go without care (OR ⫽ 0.83, 95% CI 0.70, 0.98).
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Table 2. Use of Medical Services by selected Adolescent and Parent Characteristics No Medical Exam. in Last 12 Months (32%) Characteristic Adolescent predisposing variables Age (years) 11 to 14 15 to 17 18 to 21 Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health status Excellent Very good Good Fair Poor Parent predisposing variables Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian Education Less than high school High school or GED More than high school Marital status Married Not married Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more a
(%)
p valuea
Never Had a Medical Exam. (2.2%) (%)
.08 30.0 32.8 34.5
.57 2.4 2.0 2.7
.03 31.0 31.0 35.6 36.1 40.9
.21 1.9 1.9 3.3 5.1 2.5
.00 30.6 26.5 31.7 45.6
.06 1.8 1.5 2.5 5.7
.00 26.0 32.4 36.8 39.0 19.5
.02 1.7 2.4 2.5 3.0 0.0
.00 30.8 31.0 37.2 37.1 42.9
.49 1.9 2.1 3.7 4.7 2.4
.00 36.0 34.7 29.3
.00 4.2 2.7 1.3
.24 31.6 33.2
.37 2.4 1.9
.00 32.4 36.9 30.0 27.5
p value
.01 2.3 3.2 1.9 1.0
Chi-square test.
Those whose parents had low levels of education and income, as well as those who did not work outside the home, were also more likely to forgo an annual dental visit. Never having had dental care was associated only with adolescent demographic (predisposing) charac-
teristics and parental economic (enabling) characteristics (Table 5, Model 4). Respondents born outside the United States were more than twice as likely as native-born teens to go without dental care (OR ⫽ 2.38, 95% CI 1.24, 4.59). Black and Hispanic respondents were also more than twice as likely as Whites
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Table 3. Dental Services by Selected Adolescent and Parent Characteristics No Dental Exam. in Last 12 Months (31.7%) Characteristic Adolescent predisposing variables Gender Male Female Age (years) 11 to 14 15 to 17 18 to 21 Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Place of birth United States Another country Language spoken at home English Spanish Other Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health status Excellent Very good Good Fair Poor Parent predisposing variables Age (years) 34 or younger 35 to 39 40 to 44 45 to 49 50⫹ Race/ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian Place of birth United States Another country Education Less than high school High school or GED More than high school
(%)
p valuea
Never Had a Dental Exam. (2.4%) (%)
.02 33.6 29.8
.68 2.5 2.3
.00 29.3 32.0 37.2
.60 2.7 2.3 2.0
.00 26.6 43.7 44.9 36.8 30.1
.00 1.4 4.7 5.7 1.2 2.2
.17 32.8 39.5
.03 2.2 7.2
.02 30.8 48.5 39.8
.08 2.1 8.5 4.2
.00 25.9 39.9 37.4 57.0
.00 1.6 3.6 1.7 6.7
.00 26.3 30.6 36.8 42.9 30.3
.73 2.4 2.1 2.6 3.5 4.7
.00 37.1 33.2 29.0 28.1 36.7
.01 2.4 3.5 1.9 1.3 3.0
.00 27.1 43.9 44.0 43.8 30.2
.00 1.4 4.8 6.1 2.2 2.5
.03 30.9 38.9
.03 2.1 5.3
.00 47.6 33.3 25.8
p value
.00 5.8 2.9 1.1 (Continued)
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Table 3. (Continued) No Dental Exam. in Last 12 Months (31.7%) Characteristic
(%)
Parent predisposing variables (con’t) Marital status Married Not married
28.6 39.6
Parent enabling variables Works outside the home Yes No Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more a
Never Had a Dental Exam. (2.4%)
p valuea
(%)
.00
p value .16
2.2 2.9
.00
.00
29.6 37.7
1.7 4.3 .00
.00
43.7 38.7 29.2 16.7
4.7 3.8 1.1 0.3
Chi-square test.
Table 4. Multivariate Analysis Examining Adolescents’ Use of Medical Services Characteristic Model 1: No medical visit in last year Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health Excellent/very good Good Fair/poor Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more Model 2: Never had medical examination Parent predisposing variables Education Less than high school High school or GED More than high school Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more a
Reference group
Adjusted OR
95% CI
p value
***a 0.87 0.99 1.82
(0.68, 1.10) (0.70, 1.39) (1.47, 2.25)
.24 .94 .00
(0.65, 0.94)
.01
(0.76, 1.37)
.90
1.11 1.41 1.12 ***
(0.87, 1.42) (1.16, 1.72) (0.91, 1.38)
.38 .00 .27
1.96 1.88 ***
(0.98, 3.92) (1.06, 3.33)
.06 .03
1.66 2.59 1.64 ***
(0.62, 4.46) (1.06, 6.30) (0.57, 4.68)
.31 .04 .35
0.78 *** 1.02
December 2001
PREVENTIVE CARE UTILIZATION AMONG ADOLESCENTS
403
Table 5. Multivariate Analysis Examining Adolescents’ Use of Dental Services Characteristic Model 3: No dental examination in last year Adolescent Predisposing Variables Gender Male Female Age (years) 11 to 14 15 to 17 18 to 21 Race/Ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed Heritage & Other Asian/Pacific Islander Adolescent enabling variables Health insurance Individual/group/prepaid Medicaid or Medicare Other None Adolescent need variables Perception of health Excellent/very good Good Fair/poor Parent predisposing variables Education Less than high school High school or GED More than high school Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more Works outside the home Yes No Model 4: Never had a dental examination Adolescent predisposing variables Place of birth United States Another country Race/Ethnicity White (non-Hispanic) Black (non-Hispanic) Hispanic Mixed heritage & other Asian/Pacific Islander Parent enabling variables Annual household income $19,999 or less $20,000 to $39,999 $40,000 to $59,999 $60,000 or more Works outside the home Yes No a
Reference group
Adj. OR
1.2 ***a
95% CI
p value
(1.02, 1.41)
.03
*** 1.18 1.46
(1.01, 1.37) (1.18, 1.80)
.04 .00
*** 1.70 1.46 1.44 1.08
(1.34, 2.16) (1.15, 1.84) (1.07, 1.94) (0.64, 1.82)
.00 .00 .02 .76
*** 1.16 1.42 2.23
(0.89, 1.50) (0.98, 2.06) (1.68, 2.95)
.26 .06 .00
(0.70, 0.98)
.03
(0.84, 1.56)
.38
1.44 1.07 ***
(1.13, 1.84) (0.90, 1.27)
.00 .42
2.16 2.39 1.94 ***
(1.58, 2.94) (1.89, 3.03) (1.50, 2.51)
.00 .00 .00
*** 1.23
(1.01, 1.50)
.04
*** 2.38
(1.24, 4.59)
.01
*** 2.72 2.27 0.74 0.49
(1.43, 5.16) (1.12, 4.63) (0.13, 4.38) (0.06, 4.10)
.00 .02 .74 .50
(1.99, 21.65) (2.28, 26.73) (0.78, 10.00)
.00 .00 0.11
(1.17, 3.67)
.01
0.83 *** 1.15
6.56 7.81 2.79 *** *** 2.07
404
YU ET AL.
never to have seen a dentist. Those whose parents reported incomes in the two lowest categories were 6 –7 times as likely (compared with those in highincome families) never to have received dental care.
Discussion Our multivariate analyses show that most demographic characteristics, including race/ethnicity, place of birth, and language spoken at home, are not significantly related to adolescents’ use of preventive medical care. In fact, the only significant predisposing variables related to teens’ use of preventive medical care was parents’ education, and the only significant enabling variables were insurance status and household income. The relationship between health insurance and access to medical (and dental) care is not surprising. This finding is enhanced, however, by additional information about the relationship between household income and access to preventive care: adolescents with family incomes in the low to middle range ($20,000 –$39,000) were significantly more likely than those in high-income families (with incomes of $60,000 or more) not to have had a medical or dental examination in the past year or never to have had a medical examination. (In the case of dental care, any income level below $60,000 was significantly associated with a lack of care, but the odds ratio was highest for the low-middle income group.) Thus, it would appear that those in the lowest income category, who are likely to be eligible for Medicaid, are less likely to experience access barriers than those with slightly higher incomes. (Unfortunately, the survey did not include information about family size, so it was not possible to analyze income in relationship to the federal poverty level.) After controlling for other variables, adolescents’ and their parents’ place of birth was not significantly associated with the use of medical services. However, adolescents born outside the United States were significantly more likely never to have had a dental examination. Indeed, these findings demonstrate the breadth of need for dental care, particularly among traditionally underserved populations and children of immigrant families. Nearly half of respondents who speak Spanish at home, 44% of those with low family incomes, and 48% of those whose parents have less than a high school education did not receive a dental examination in the past year. Uninsured teens were also twice as likely as those with private insurance not to have received a dental
JOURNAL OF ADOLESCENT HEALTH Vol. 29, No. 6
checkup. Even among Medicaid recipients, who are theoretically entitled to dental benefits, nearly 40% had no dental visit in the year before the survey. It appears that the use of dental care is vulnerable to any of a number of factors; although the overall proportion of respondents who did not receive an annual dental visit did not differ greatly from the proportion that did not receive a medical examination, barriers to the use of dental services abound, including educational barriers, language barriers, economic barriers, and a lack of available providers for those enrolled in Medicaid [22,23]. Two potential limitations of this study should be noted. First, the data on adolescents’ use of health services are self-reported. Adolescents’ reports of health care utilization were not confirmed with medical records. Second, the Add Health sample was drawn using schools. As a result, adolescents who are not enrolled in school were excluded from this study. This population may include high-risk youth who have dropped out of school or those with chronic or disabling conditions. Therefore, the study results will not apply to adolescents who are not enrolled in school. These findings are particularly timely as states implement Medicaid expansions and separate state health insurance programs under the State Child Health Insurance Program (SCHIP) authorized under the Balanced Budget Act of 1997. A large proportion of children eligible for these programs are likely to be adolescents, as Medicaid’s previous income eligibility standards were stricter for adolescents than for younger children. These findings demonstrate the need to promote the importance of preventive medical and dental care to previously uninsured teens, many of whom may be unaccustomed to regular well-child visits. Particularly in the case of dental care, those children who make up the majority of SCHIP eligibles, Hispanic children of low-income working parents, are the most likely to have gone without care in the past and to demonstrate pent-up demand for services. Moreover, children in immigrant families, who may be reluctant to enroll in SCHIP for legal reasons, will require targeted outreach to assure that they are able to use the services for which they are now eligible.
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