Pediatrics (Journal of American Academy of Pediatrics)

126 Pages·2007·0.94 MB·English

Pediatrics (Journal of American Academy of Pediatrics)

February 2007 | Volume 119 | Issue Supplement,pp.1-123

National and State-Specific Findings From the National Survey of Children's Health
Pediatrics 2007; 119: A1.
SUPPLEMENT ARTICLES
Introduction to the Volume on Articles From the National Survey of Children's Health
Michael D. Kogan and Paul W. Newacheck
Pediatrics 2007; 119: S1-S3.
The Association of Health Insurance and Continuous Primary Care in the Medical Home

on Vaccination Coverage for 19- to 35-Month-Old Children
Norma J. Allred, Karen G. Wooten, and Yuan Kong
Pediatrics 2007; 119: S4-S11.
Disparities in Dental Insurance Coverage and Dental Care Among US Children: The

National Survey of Children's Health
Jihong Liu, Janice C. Probst, Amy B. Martin, Jong-Yi Wang, and Carlos F. Salinas
Pediatrics 2007; 119: S12-S21.
Children's Mental Health and Family Functioning in Rhode Island

Hyun (Hanna) K. Kim, Samara I. Viner-Brown, and Jorge Garcia
Pediatrics 2007; 119: S22-S28.
Sleepless in America: Inadequate Sleep and Relationships to Health and Well-being of

Our Nation's Children
Arlene Smaldone, Judy C. Honig, and Mary W. Byrne
Pediatrics 2007; 119: S29-S37.
Nativity/Immigrant Status, Race/Ethnicity, and Socioeconomic Determinants of

Breastfeeding Initiation and Duration in the United States, 2003
Gopal K. Singh, Michael D. Kogan, and Deborah L. Dee
Pediatrics 2007; 119: S38-S46.
Risk and Promotive Factors in Families, Schools, and Communities: A Contextual Model

of Positive Youth Development in Adolescence
Lise M. Youngblade, Christina Theokas, John Schulenberg, Laura Curry, I-Chan Huang, and Maureen
Novak
Pediatrics 2007; 119: S47-S53.
The Health and Well-being of Adopted Children

Matthew D. Bramlett, Laura F. Radel, and Stephen J. Blumberg
Pediatrics 2007; 119: S54-S60.
Factors Associated With Not Having a Personal Health Care Provider for Children in

Florida
Mary Beth Zeni, William Sappenfield, Dan Thompson, and Hailin Chen
Pediatrics 2007; 119: S61-S67.
The Prevalence of Violent Disagreements in US Families: Effects of Residence,

Race/Ethnicity, and Parental Stress
Charity G. Moore, Janice C. Probst, Mark Tompkins, Steven Cuffe, and Amy B. Martin
Pediatrics 2007; 119: S68-S76.
Lifetime Prevalence of Learning Disability Among US Children

Maja Altarac and Ekta Saroha
Pediatrics 2007; 119: S77-S83.
A Multilevel Study of the Associations Between Economic and Social Context, Stage of

Adolescence, and Physical Activity and Body Mass Index
Caroline Mae McKay, Bethany A. Bell-Ellison, Kirsten Wallace, and John M. Ferron
Pediatrics 2007; 119: S84-S91.
Associations Between Breastfeeding Practices and Young Children's Language and Motor

Skill Development
Deborah L. Dee, Ruowei Li, Li-Ching Lee, and Laurence M. Grummer-Strawn
Pediatrics 2007; 119: S92-S98.
National Estimates and Factors Associated With Medication Treatment for Childhood

Attention-Deficit/Hyperactivity Disorder
Susanna N. Visser, Catherine A. Lesesne, and Ruth Perou
Pediatrics 2007; 119: S99-S106.
Does Access to a Medical Home Differ According to Child and Family Characteristics,

Including Special-Health-Care-Needs Status, Among Children in Alabama?
Beverly A. Mulvihill, Maja Altarac, Shailender Swaminathan, Russell S. Kirby, Andrzej Kulczycki, and
Dawn E. Ellis
Pediatrics 2007; 119: S107-S113.
The Relationship Between Autism and Parenting Stress

Laura A. Schieve, Stephen J. Blumberg, Catherine Rice, Susanna N. Visser, and Coleen Boyle
Pediatrics 2007; 119: S114-S121.
Final Commentary on the Special Volume of Articles From the National Survey of
Children's Health
Peter C. van Dyck
Pediatrics 2007; 119: S122-S123.
P E D IAT R IC S
OFFICIALJOURNALOFTHEAMERICANACADEMYOFPEDIATRICS
FEBRUARY2007•VOLUME119•SUPPLEMENT1
A SUPPLEMENT TO PEDIATRICS
National and State-Specific Findings From the
National Survey of Children’s Health
Michael D. Kogan, PhD, and Paul W. Newacheck, PhD,
Supplement Co-editors
Sponsored by the Maternal and Child Health Bureau
Health Resources and Services Administration
Statements and opinions expressed in this supplement are those of
the authors and not necessarily those of the American Academy of
Pediatrics, its committees, Pediatrics, or the Editor or Editorial
Board of Pediatrics
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275); published
inthepublicdomainbytheAmericanAcademyofPediatrics

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SUPPLEMENTARTICLE
Introduction to the Volume on Articles From the
National Survey of Children’s Health
MichaelD.Kogan,PhDa,PaulW.Newacheck,DrPHb
aMaternalandChildHealthBureau,HealthResourcesandServicesAdministration,Rockville,Maryland;bUniversityofCalifornia,InstituteforHealthPolicyStudiesand
DepartmentofPediatrics,SanFrancisco,California
Theauthorshaveindicatedtheyhavenofinancialrelationshipsrelevanttothisarticletodisclose.
A
T THE BEGINNING of the 21st century, researchers, Toincreaseefficiencyandlowercosts,theNSCHshared
policymakers and advocates had surprisingly few the sampling frame of the National Immunization Sur-
sources of analytic data concerning key issues in the vey. All interviews used computer-assisted telephone
healthy development and well-being of children and interviewing. The survey was conducted in all 50 states
theirfamiliesintheUnitedStates.Moreover,therewas andtheDistrictofColumbia.Householdswerescreened
often no information about the health of children in to identify the presence of children under 18 years old.
individualstatesbeyondtheperinatalperiod.TheHealth In eligible households, 1 child under 18 was selected
Resources and Services Administration’s Maternal and
randomlytobethesubjectoftheinterview.Therespon-
Child Health Bureau (MCHB), which is charged with
dentwasthemostknowledgeableadultaboutthechild.
promoting and improving the health of the nation’s
Seventy-nine percent of interviews were conducted
mothers and children, implemented a set of new data
with the child’s mother, the father was the respondent
initiativestoaddressthosegaps.In2001,theMCHB,in
17%ofthetime,and3%ofthetimeitwasagrandpar-
collaboration with the Centers for Disease Control and
ent.2
Prevention’s National Center for Health Statistics
The NSCH was a unique survey for a number of
(NCHS), conducted the National Survey of Children
reasons. First, it was one of the largest surveys ever
With Special Health Care Needs, a random-digit-dial
conducted on the health of America’s children: inter-
survey of almost 40000 children considered to have
views were conducted with the parents or guardians of
special needs. The survey was designed to provide both
(cid:1)102353childrenfrombirthtoage18years.Thelarge
national- and state-level estimates for this population.1
sample size allowed for the examination of relatively
From January 2003 through July 2004, the MCHB
uncommon conditions or circumstances. Second, the
conducted the National Survey of Children’s Health
(NSCH). The NSCH was created to serve a number of surveywasdesignedtoprovidebothnational-andstate-
purposes. Its primary purpose was to provide estimates levelestimates.Itwasthefirstsurveyoftheoverallchild
at the both the national- and state-level for a variety of healthpopulationintheUnitedStatesthatallowedanal-
physical, emotional, and behavioral child health indica-
KeyWords:familyissues,accesstohealthcare,ADHD,adolescence,breastfeeding
tors.Thesedataweredesignedtohelpguidepolicymak- Abbreviations:MCHB,MaternalandChildHealthBureau;NCHS,NationalCenterfor
ers,advocates,andresearchersonchildhealth.Another HealthStatistics;NSCH,NationalSurveyofChildren’sHealth
purposewastoprovidebaselineestimatesforanumber Theviewsinthisarticlearetheauthors’anddonotnecessarilyreflecttheviewsofthe
institutionswithwhichtheauthorsareaffiliated.
offederalandstateprograms,suchastheTitleVmater-
www.pediatrics.org/cgi/doi/10.1542/peds.2006-2089B
nal and child health performance measures, Healthy
People 2010, and each state’s 5-year Title V needs as- doi:10.1542/peds.2006-2089B
sessment. AcceptedforpublicationSep15,2006
AddresscorrespondencetoMichaelD.Kogan,PhD,MaternalandChildHealthBureau,Health
The NSCH was conducted through random-digit di- ResourcesandServicesAdministration,5600FishersLane,Room18-41,Rockville,MD20857.E-mail:
aling. Interviews were conducted in either English or [email protected]
PEDIATRICS(ISSNNumbers:Print,0031-4005;Online,1098-4275);publishedinthepublicdomainby
Spanish;5.9%ofinterviewswereconductedinSpanish. theAmericanAcademyofPediatrics
PEDIATRICSVolume119,Supplement1,February2007 S1

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ysesatthestatelevel.Third,althoughtherewasa“core” were less likely to receive preventive dental care, even
set of questions asked of all children, there were also afteraccountingforinsurancestatus.Visseretal(pS99)
separate,age-specificmodules,forchildrenages0to5,6 studiedmedicationusageamongchildrenwithreported
to 11, and 12 to 17 years. Fourth, the survey was de- attention-deficit/hyperactivitydisorder,withanempha-
signedtotakeabroaderapproachtoexaminingthelives sisongender-specificfactorsassociatedwithmedication
ofchildren;therewerequestionsnotonlyonthehealth usage.Theyfoundthathavinghealthcarecoverageand
conditions of the child, but also questions about their higher incomes were significantly associated with med-
familiesandtheirneighborhoods.Inaddition,therewas ication use for boys but not girls.
afocusonfactorsthatpromoteresilienceandwell-being One of the primary motivations for this survey was
in children. the relative dearth of information on child health that
The 15 articles in this special issue highlight each of wasavailableatthestatelevel.Threearticlesinthisissue
theuniqueaspectsoftheNSCH.ThearticlebyBramlett feature state-level analyses. Kim et al (p S22) drew on
et al (p S54) on the health and well-being of adopted earlier work in Rhode Island indicating there were in-
childrentookadvantageofthelargesamplesizetocom- adequate resources for children’s mental health to ex-
pare adopted and biological children on various indica- aminetheassociationbetweenchildren’smentalhealth
tors of health. They found that adopted children were and family functioning in that state. They found that
ofteninpoorerhealth,butmorelikelytoreceiveneeded almost 20% of Rhode Island children were reported to
health care. Schieve et al (p S114) examined the rela- have a mental health problem, and that the parents of
tively rare outcome of autism, focusing on the relation- childrenwithmentalhealthproblemswere(cid:2)4timesas
ship between autism and parenting stress. They com- likely to consider themselves highly stressed as parents
pared the responses from parents of children identified ofchildrenwithoutmentalhealthissues.Mulvihilletal
as having autism with parents of: (a) children who had (p S107) focused on the comparisons between children
special health care needs who had emotional, develop- withandwithoutaspecialhealthcareneedwithregard
mental, or behavioral problems other than autism, (b) toaccesstoamedicalhomeinAlabama.Theyfoundthat
childrenwithspecialhealthcareneedswhodidnothave although children with special health care needs were
emotional, developmental, or behavioral problems, and more likely to have the basic services, they were also
(c) children without special health care needs on the more likely to experience problems with accessing spe-
Aggravation in Parenting scale. Their findings indicated cialtycare,equipment,orservices.Zenietal(pS61)set
thatparentsofchildrenwithautismweremostlikelyto out to examine factors associated with not having a
score high on this scale, and within the autism group, personalhealthcareproviderforchildreninFloridaafter
parents whose child recently needed special services preliminary analyses indicated that Florida had a lower
were at even higher risk. Altarac and Saroha (p S77) rate of children with a personal doctor or nurse com-
assessed the lifetime prevalence of learning disabilities pared with all US children. They found that lack of
and its association with the presence of special health health care provider is driven less by a child’s health
care needs. They found learning disabilities to be an statusandmorebylargercommunityissues,suchaslack
important comorbidity among children with special of health insurance or higher levels of poverty.
heath care needs, especially among those with multiple Somearticlesinthisissuefocusedexclusivelyonspe-
special needs. cificagegroups.Smaldoneetal(pS29)identifiedchar-
The large sample size enabled Moore et al (p S68) to acteristics associated with inadequate sleep among ele-
use measures of urbanicity in their article on the prev- mentary school-aged children and adolescents. They
alence of violent disagreements in US families and the found that parents reporting that their children had
effects of race-ethnicity, residence, and parental stress. inadequate sleep were also more likely to report the
Theyfoundthatmorethan10%ofUSchildrenlivedin child displayed depressive symptomatology, have con-
homes with reported violent disagreements. Moreover, cerns about the child’s safety, and report more heated
theyreportedthatviolentdisagreementsvariedbyrace- family disagreements. The authors stressed the point
ethnicityandurbanicity,withparentsinruralareasless that pediatricians should routinely identify and address
likely to report violent disagreements than parents in inadequate sleep and its associated health, school, and
urban areas. Their findings could help pediatricians un- familyfactors.Deeetal(pS92)addressedtheassociation
derstandwhichfamiliesmaybeathigherriskforviolent betweenbreastfeedingpracticesandlanguageandmotor
disagreements.Levelofurbanicitywasalsoakeyfactor skilldevelopmentamongchildren10to71monthsold.
intheanalysisbyLiuetal(pS12).TheylinkedtheNSCH Their analyses revealed that mothers who initiated
to the Area Resource File in a study on disparities in breastfeeding were less likely than mothers of never
dental insurance coverage and dental care among US breastfed children to be concerned a lot about their
children. Among their more prominent findings, Liu et children’s language development. Moreover, there
al found that rural children were less likely to have seemed to be an association between level of concern
dental insurance, and that poor and minority children and length of breastfeeding, with the longer a mother
S2 KOGAN,NEWACHECK

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breastfed, the less likely she was to express concerns Youth who were involved in contexts that provided
about language. Singh et al (p S38) examined the asso- positive resources from important others (ie, parents,
ciation between nativity/immigrant status, race/ethnic- schools, and communities) not only were less likely to
ity, and socioeconomic determinants and breastfeeding exhibit negative outcomes but also were more likely to
initiationandduration.Theyfoundthatforall12ofthe show evidence of positive development. These findings
ethnic-immigrant groups studied, immigrant women provideimportantimplicationsforinterventionandpre-
had higher breastfeeding initiation and longer duration ventioneffortsand,moregenerally,forthepromotionof
rates than native women. Allred et al (p S4) looked at positive, competent, and healthy youth development.
the association of continuous care in the medical home The final commentary by van Dyck (p S122) focuses
and health insurance on up-to-date vaccination cover- notonlyonwhereweneedtoconcentrateoureffortsto
age by using merged data from the NSCH and the Na- improvechildren’shealthbutalsotouchesontheplans
tional Immunization Survey among children 19 to 35 for future rounds of this survey.
months old. Their findings indicated that in bivariate Thiscollectionofarticlesprovidesasenseofboththe
analyses, children were more likely to be vaccinated if breadthanddepthofinformationavailableintheNSCH,
theyhadcontinuouscoverageinthemedicalhomeand as well as its analytical potential. We expect that the
health insurance coverage. However, in multivariate survey will be widely used in the years to come by
analyses, only marital status was significant, with those policymakers, researchers, and advocates concerned
childrenfromnever-marriedmothersbeinglesslikelyto with improving the health and well-being of children
be vaccinated.
and their families. Microdata from the survey are avail-
ThearticlebyMcKayetal(pS84)ontheassociations
ableatnocostfromtheNCHSWebsite(www.cdc.gov/
between economic and social context, stage of adoles-
nchs/slaits.htm) or the MCHB Web site (www.mchb.
cence, and physical activity and BMI is a good example
hrsa.gov/programs/dataepi). Interested users can also
of the multilevel analyses that can be drawn from this
access the data interactively at the MCHB-funded Data
study. They found that both state-level mutual aid and
ResourceCenter(www.nschdata.org).Inaddition,ase-
social trust were significantly related to the odds of an
ries of MCHB-supported chart books on children’s
adolescent not meeting current physical activity recom-
health and well-being, oral health, obesity, and rural
mendations.ForBMI,state-levelmutualaid,socialtrust,
healthareavailableinelectronic(http://mchb.hrsa.gov)
andstate-levelpovertywereallassociatedwithhavinga
and paper form.
higher-than-normal BMI.
ThearticlebyYoungbladeetal(pS47)isanexcellent
study on the factors associated with positive develop- REFERENCES
ment in adolescents. They assessed a contextual model 1. BlumbergSJ,OlsonL,FrankelM,etal.Designandoperationof
derivedfrompositiveyouthdevelopmenttheorybyex- the National Survey of Children With Special Health Care
amining the association of family, school, and commu- Needs, 2001. National Center for Health Statistics. Vital Health
Stat1.2003;(41):1–136
nity risk and promotive factors with several outcome
2. BlumbergSJ,OlsonL,FrankelM,OsbornL,SrinathKP,Giambo
indicesofbothpositiveandnegativeadolscentdevelop-
P. Design and operation of the National Survey of Children’s
ment.Theirresultssupportthepropositionthathealthy
Health,2003.NationalCenterforHealthStatistics.VitalHealth
adolescent development has roots in multiple contexts. Stat1.2005;(43):1–124
PEDIATRICSVolume119,Supplement1,February2007 S3

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SUPPLEMENTARTICLE
The Association of Health Insurance and Continuous
Primary Care in the Medical Home on Vaccination
Coverage for 19- to 35-Month-Old Children
NormaJ.Allred,PhD,MSN,KarenG.Wooten,MA,YuanKong,MS
NationalCenterforImmunizationandRespiratoryDiseases(proposed),DivisionofImmunizationServices,CentersforDiseaseControlandPrevention,Atlanta,Georgia
Theauthorshaveindicatedtheyhavenofinancialrelationshipsrelevanttothisarticletodisclose.
ABSTRACT
OBJECTIVE.Ourgoalwastoexaminetheassociationofcontinuouscareinthemedical
homeandhealthinsuranceonup-to-datevaccinationcoveragebyusingdatafrom
www.pediatrics.org/cgi/doi/10.1542/
theNationalSurveyofChildren’sHealthandtheNationalImmunizationSurvey.
peds.2006-2089C
METHODS.Interviews were conducted with 5400 parents of 19- to 35-month-old doi:10.1542/peds.2006-2089C
children to collect data on demographics and medically-verified vaccinations. Theviewsinthisarticlearethoseofthe
Healthinsurancecoveragewascategorizedasalways,intermittently,oruninsured authorsanddonotnecessarilyrepresent
theviewsoftheCentersforDisease
for the previous 12 months. Insurance types were private, public, or uninsured. ControlandPrevention,USDepartmentof
Having a personal doctor or nurse and receiving preventive health care in either HealthandHumanServices.
the past 12 or 24 months constituted continuous primary care in the medical KeyWords
vaccination,healthinsurance,continuityof
home. Children were up-to-date if they received all vaccinations by 19 to 35
patientcare
monthsofage((cid:1)4dosesofdiphtheriaandtetanustoxoidsandpertussisvaccine,
Abbreviations
(cid:1)3 doses of poliovirus vaccine, (cid:1)1 dose of any measles-containing vaccine, (cid:1)3 VFC—VaccinesforChildren
doses of Haemophilus influenzae type b vaccine, and (cid:1)3 doses of hepatitis B vac- UTD—up-to-date
NSCH—NationalSurveyofChildren’s
cine). Health
NIS—NationalImmunizationSurvey
RESULTS.Bivariate analyses revealed children who were always insured had signif- CDC—CentersforDiseaseControland
icantly higher vaccination coverage (83%) than those with lapses or uninsured Prevention
WIC—SpecialSupplementalNutrition
during the past 12 months (75% and 71%, respectively). Those with continuous ProgramforWomen,Infants,andChildren
primary care in the medical home had significantly higher coverage than those OR—oddsratio
CI—confidenceinterval
whodidnot(83%vs75%,respectively).Inmultivariateanalysis,thesamepattern 4:3:1:3:3—(cid:1)4dosesofdiphtheriaand
of association was observed for insurance status and medical home, but the only tetanustoxoidsandpertussisvaccine,(cid:1)3
dosesofpoliovirusvaccine,(cid:1)1doseof
statisticallysignificantassociationwasforchildrenofnever-marriedmotherswho
anymeasles-containingvaccine,(cid:1)3doses
hadsignificantlylowercoverage(74%)comparedwithchildrenofmarriedmoth- ofHaemophilusinfluenzaetypebvaccine,
ers (84%). and(cid:1)3dosesofhepatitisBvaccine
AcceptedforpublicationSep15,2006
CONCLUSIONS.Amongchildrenwiththesameinsurancestatusandcontinuityofcare AddresscorrespondencetoNormaJ.Allred,
in the medical home, children of single mothers were less likely to be up-to-date PhD,MSN,NationalCenterforImmunization
andRespiratoryDiseases,CentersforDisease
thanchildrenofmarriedmothers.Interventionsassistingsinglemotherstoobtain
ControlandPrevention,1600CliftonRdNE,
preventive care for their children should be a priority. MailstopE52,Atlanta,GA30333.E-mail:
[email protected]
PEDIATRICS(ISSNNumbers:Print,0031-4005;
Online,1098-4275);publishedinthepublic
domainbytheAmericanAcademyof
Pediatrics
S4 ALLREDetal

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I
SSUESAFFECTINGPEDIATRICaccesstohealthcarehave METHODS
been studied extensively, and one concept that has TheNationalSurveyofChildren’sHealth(NSCH)wasa
been a priority for researchers is that of the medical module of the State and Local Area Integrated Tele-
home. In 1992, the American Academy of Pediatrics phoneSurvey,whichisabroad-based,ongoingsurveil-
issued its first policy statement, which provided a defi- lance system that uses the sampling frame of the Na-
nitionofthemedicalhome:“thatmedicalcareofinfants, tionalImmunizationSurvey(NIS),conductedjointlyby
children and adolescents should be accessible, continu- the Centers for Disease Control and Prevention’s
ous, comprehensive, family-centered, coordinated and (CDC’s) National Center for Health Statistics and the
compassionate. It should be delivered or directed by National Immunization Program. The survey design is
well-trainedphysicianswhoareabletomanageorfacil- described briefly in the article by Kogan and Newa-
itateessentiallyallaspectsofmedicalcare.Thephysician check18; more in-depth information can be found else-
shouldbeknowntothechildandfamilyandshouldbe where.19 The NIS is a random-digit dialed telephone
able to develop a partnership of mutual responsibility survey conducted annually by the CDC to obtain na-
andtrustwiththem.”Themedicalhomeshouldprovide tional,state,andselectedurban-areaestimatesofvacci-
nationcoverageforUSchildrenaged19to35monthsat
preventive services, such as well-child care and immu-
nizationdelivery,andtheseservicesshouldbeprovided the time of the interview.20 It includes household- and
child-specificinformationfromthemostknowledgeable
over an extended period of time to enhance continuity
respondent concerning the child’s vaccination history
of care.1 However, costs related to obtaining ongoing
followed by a mail survey to vaccination providers to
primary care, as well as vaccinations in the medical
verify vaccination information. Human subjects review
home, have posed a barrier for children who are unin-
was not required for this study.
sured or underinsured.2
In 1994, the Vaccines for Children (VFC) program
NSCH-NISLinkage
was instituted to assist children in remaining in their
TheNSCHquestionnairewasdesignedtofollowacom-
medicalhomeforvaccinations.3VFCreducedthecostof
pletedNISinterviewinhouseholdswithanNIS-eligible
obtaining childhood vaccinations by providing publicly
child or the NIS screener in households without an
purchased vaccines at no charge to enrolled health care
NIS-eligiblechild.TheNSCHresponseswereweightedto
providers. Before VFC implementation, private provid-
estimatetheUSpopulationofchildren,age-adjustedfor
erswouldoftenreferparentswhocouldnotaffordvac-
nonresponseandunequalprobabilityofselection.Ofthe
cines to health departments, thus fragmenting medical
102353NSCHchildreninthestudy,6976were19to35
care.4TheeffectofVFChasbeentominimizethatprac-
monthsofage.Ofthese,420NSCHrecordswereunable
tice,theoutcomebeingagreaterpercentageofchildren
to be linked to NIS records, leaving 6556 subjects who
obtaining vaccinations in their medical home3,5–7 and a
had completed interviews from both NSCH and NIS
resultantriseinvaccinationratesovertheyearssinceits
surveys. Ninety-seven percent of these records were
implementation.
linkedacrosssurveysviaauniquehouseholdidentifier;
Several studies have examined the association be-
the remaining 3% were linked by a combination of
tweenhavingregularpreventivecarevisitsandvaccina-
household identifier and demographic characteristics or
tion coverage for young children.8–10 However, only a
assigned randomly within the household when it was
few have created a definition of the medical home to
impossible to determine which twin or triplet was the
examine how this factor influences vaccination cover-
child who had been selected randomly for the NSCH
age.8,11,12 The association between type of health insur- sample. Of the 6556 linked observations, adequate pro-
ance and continuity of insurance coverage with vacci- vider-verifiedvaccinationdatawereobtainedduringthe
nationcoveragehavealsobeenevaluated.13–17However, NISdatacollectionfor5400children,19to35monthsof
mostofthestudiesexamininghealthinsurancecoverage age,andallanalyseswerebasedonthese5400children.
havelookedathowthepresenceorabsenceofinsurance Wefurtheradjustedtheweightsforthese5400children
affected vaccination coverage but were not able to take to account for provider nonresponse and incomplete
into account the effect of insurance lapses on vaccina- response to vaccine record requests.
tion rates.
Weusedanationallyrepresentativesampletoexam- VariablesandDefinitions
ine how up-to-date (UTD) vaccination coverage for 19- Both surveys provided variables for the analyses. Vari-
to 35-month-old children was associated with continu- ablesfromtheNSCHincluded:typeofhealthinsurance
ous primary care in a medical home, type of health at the time of the interview (private, public, or unin-
insurance, and lapses in health insurance coverage. As sured),healthinsurancecoveragefor12monthsbefore
additionalchildhoodvaccinesareaddedtotheschedule, interview date (always, intermittently, or never in-
understanding the impact of these factors on vaccine sured),highesteducationallevelofanyoneinthehouse-
delivery becomes more important. hold, identification of a personal doctor or nurse who
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knows the child well and is familiar with the child’s insured for the 12 months before the interview date.
health history, and receiving preventive health care Mothers of almost half of the children (46%) and the
from the child’s personal doctor or nurse in either the highest-educated household member of nearly three
past12or24monthsbeforetheinterviewdate.Contin- fourths of the children (73%) had more than a high
uous care in the medical home was based on whether school education. Eighty-five percent reported having a
the respondent stated (a) they had a personal doctor or personal doctor or nurse who was familiar with their
nursefortheirchildwhoknowsthechildwellandwas child’shealthhistory.Ofthosechildrenwhohadaper-
familiarwiththechild’shealthhistory,and(b)thechild sonal doctor or nurse, 85% received preventive health
hadreceivedpreventivehealthcareineitherthepast12 care in either the past 12 or 24 months before the
or 24 months from the same personal doctor or nurse. interview, with 88% receiving care in the 12 months.
VariablesfromtheNISincludedprovider-verifiedvacci- Eighty percent of the children were categorized as re-
nation data, race/ethnicity of child, poverty status, his- ceiving continuous primary care in the medical home.
tory of participation in the Special Supplemental Nutri- The majority of children lived in households with in-
tion Program for Women, Infants and Children (WIC), come at or above the federal poverty level (77%). Al-
birthorder,maternalage,educationallevel,andmarital most half of the children’s mothers (42%) had ever
status.Anadditionalvariablewascreatedthatcombined participatedinWIC,and19%werereceivingWICben-
health insurance coverage for the past 12 months and efitsatthetimeoftheinterview.Themajority(77%)of
current insurance type into 4 levels: always insured, mothers were married, with 17% classified as never
private health insurance; always insured, public health married at the time of the child’s birth.
insurance; intermittently insured, either type of insur-
ance; and never insured. This new variable was created VaccinationCoverage
to allow for the inclusion of these 2 variables in the Table2describestheresultsoftheassociationsbetween
modeling, because a cross-tabulation of insurance type thesociodemographicvariablesandUTDstatus.Eighty-
and insurance coverage would result in empty cells. threepercent(4456)ofthechildrenwereUTDwiththe
AchildwasUTDforvaccinationcoverageiftheyhad 4:3:1:3:3vaccinationseries((cid:1)4dosesofdiphtheriaand
received(cid:1)4dosesofdiphtheriaandtetanustoxoidsand tetanus toxoids and pertussis vaccine, (cid:1)3 doses of po-
pertussis vaccine, (cid:1)3 doses of poliovirus vaccine, (cid:1)1 liovirusvaccine,(cid:1)1doseofanymeasles-containingvac-
dose of any measles-containing vaccine, (cid:1)3 doses of cine, (cid:1)3 doses of Haemophilus influenzae type b vaccine,
Haemophilus influenzae type b vaccine, and (cid:1)3 doses of and (cid:1)3 doses of hepatitis B vaccine). Vaccination cov-
hepatitis B vaccine by the time of the household inter- erage for children with private insurance was 84%,
view. whichwassignificantlyhighercomparedwithcoverage
of79%amongchildrenwithpublicinsuranceand71%
StatisticalAnalyses fortheuninsured.Coverageforchildrenwhohadlapses
(cid:2)2 analyses were performed to test for associations be- in health insurance was also significantly lower com-
pared with coverage for children who were always in-
tween the sociodemographic and health care variables
sured(75%vs83%,respectively).Childrenwhodidnot
and vaccination coverage. Logistic regression analyses
havecontinuousprimarycareinthemedicalhomehad
testedfortheassociationofcontinuouscareinthemed-
significantly lower vaccination coverage (75%) com-
ical home and health insurance coverage by insurance
pared with those who had had coverage (83%). Chil-
type with UTD vaccination status while controlling for
dren who did not have a personal doctor or nurse, did
covariates. Adjusted odds ratios (ORs) and 95% confi-
not receive preventive health care in either the past 12
denceintervals(CIs)arereported.Inaddition,predictive
or 24 months, were of Hispanic or black race/ethnicity,
marginals were used to calculate adjusted vaccination
everreceivedWICbenefits,wereborntoamother(cid:1)30
coverage estimates and are reported with respective
yearsold,orwhosemotherwasnotmarriedatthetime
95%CIsexpressedashalf-widths.A2-sidedsignificance
of the child’s birth had significantly lower vaccination
level of 0.05 was adopted for all statistical tests. All
coverage when compared with the referent group for
analyses were conducted by using SAS 8.02 (SAS Insti-
that particular characteristic.
tute, Inc, Cary, NC) and SAS-callable SUDAAN 9.01
(Research Triangle Institute, Research Triangle Park,
MultivariateLogisticRegression
NC).21
Multivariatelogisticregressionanalysesusingbackward
eliminationwereconductedtodeterminethelikelihood
RESULTS
of UTD immunization coverage with continuous pri-
SurveyRespondents mary care in the medical home and health insurance
Table1describesthesociodemographiccharacteristicsof coverage by insurance type while controlling for signif-
the 5400 respondents. Approximately 66% of children icantcovariatesthatincludedrace/ethnicityofthechild,
had private insurance, with the majority (87%) always WICstatus,andmother’sageandmaritalstatusandthe
S6 ALLREDetal

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TABLE1 CharacteristicsofStudySample:NCSH,2003(N(cid:1)5400)
VariableDescription Samplen,Unweighted %,Weighted
Currenthealthinsurancetypea
Private 3498 65.5
Public 1471 27.6
Uninsured 370 6.9
Healthinsurancecoverageforpast12mo
Alwaysinsured 4612 86.6
Intermittentlyinsured 559 10.5
Neverinsured 153 2.9
Highestleveleducationattainedbyanyoneinhousehold
Lessthanhighschool 343 6.4
Highschoolgraduate(12y) 1072 19.9
Morethanhighschool 3985 73.2
Identified(cid:1)1personsaschild’spersonaldoctorornurse
Yes 4564 84.7
No 826 15.3
Continuousprimarycareinmedicalhomeb
Yes 4317 80.1
No 1073 19.9
Preventivehealthcareineitherthepast12or24mo
Yes 4317 85.3
No 743 14.7
Race/ethnicityofchild
Hispanic 860 15.9
White,non-Hispanic 3649 67.7
Black,non-Hispanic 398 7.4
Other,non-Hispanic 487 9.0
Povertystatus
(cid:1)1.0,abovepovertylevel 4159 77.0
(cid:1)1.0,belowpovertylevel 804 14.9
Unknown 437 8.1
WICstatus
Currentlyreceive 1258 23.3
Everreceived 1024 19.1
Neverreceived 3074 57.6
Mother’seducation
(cid:1)12y 573 10.6
12y 1301 24.1
(cid:2)12,notcollegegraduate 1067 19.8
Collegegraduate 2459 45.5
Mother’smaritalstatus
Widowed,divorced,separated,ordeceased 341 6.3
Nevermarried 916 17.0
Married 4142 76.7
Mother’sage,y
(cid:3)19 125 2.3
20–29 2377 44.0
(cid:1)30 2898 53.7
First-bornchild
No 2222 41.1
Yes 3178 58.9
Healthinsurancecoveragepast12mobycurrentinsurancetype
Alwaysinsured,privateinsurance 3339 62.7
Alwaysinsured,publicinsurance 1273 23.9
Intermittentlyinsured,eitherpublicorprivateinsurance 559 10.5
Notinsured 153 2.9
aPrivatehealthinsurancereferredtoanytypeofhealthinsurance,includinghealthmaintenanceorganizations,otherthanpublicprograms.
PublichealthinsurancewasdefinedaseitherMedicaidoraStateChildren’sHealthInsuranceProgram.Insurancetypewasmeasuredonlyatthe
timeoftheinterview.
bAchildwasdeterminedtohavereceivedcontinuouscareinthemedicalhomeiftherespondentstatedthatheorshehadanidentifiedpersonal
doctorornurseforthechildwhoknewthechildwellandwasfamiliarwiththechild’shealthhistoryandthechildhadreceivedpreventivehealth
ineitherthepast12or24monthsbeforetheinterviewfromthepersonaldoctorornurse.
Datesource:CentersforDiseaseControlandPrevention,NationalCenterforHealthStatistics,StateandLocalAreaIntegratedTelephoneSurvey,
NSCH,2003.
PEDIATRICSVolume119,Supplement1,February2007 S7

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