1. Psychological Distress and Timely Use of Routine Care: The Importance of Having Health Insurance and a Usual Source of Care among Women with Children Whitney P. Witt, PhD, MPH Ninth Annual Maternal and Child Health Epidemiology Conference December 11, 2003

2. Other Contributors Timothy Ferris, MD Lisa Fortuna, MD, MPH Robert Kahn, MD, MPH Karen Kuhlthau, PhD Paul Pirraglia, MD, MPH Jonathan Winickoff, MD, MPH

3. Structure of Talk Background Methods Results Summary conclusions Strengths and limitations Policy implications

4. Background (1) Having health insurance and a usual source (USC) of care facilitate access to healthcare –Often not having a USC is a stronger predictor of delays in care USC is associated with increased use of preventive services in adults (Ettner, 1999) and cancer screening in women (Zapka et al 1989 and 1992; Ettner 1996)

5. Background (2) However the use of preventive services for women has not been examined in the context of psychological distress –No studies on women with children Impact of maternal psychological distress on preventive healthcare practices and service use in the family is not well understood

6. Specific Aims This study aims to understand the relationship between maternal psychological distress, health insurance status, and having a usual source of care with the use of routine care among women with children

7. Hypotheses Maternal psychological distress will be associated with delayed routine care Absence of a usual source of care and no health insurance will be associated with delayed routine care

8. Conceptual Framework Maternal psychological distress Mother Child Preventive Health practices Preventive Health practices Health and mental health status Health and mental health status Healthcare use Healthcare use

9. Conceptual Framework Mother Child Preventive Health practices Preventive Health practices Maternal psychological distress Health and mental health status Health and mental health status Healthcare use Healthcare use

10. Methods

11. Sample and Data Source Sample consists of 5,825 mothers between the ages of 18-49 1998 National Health Interview Survey (NHIS), Adult Prevention Module

12. Independent Variables (1) Maternal psychological distress –Measured by a six-item distress battery with known psychometric properties and accuracy in discriminating DSM-IV defined depression (Kessler et al 2002) –Mothers with mild-moderate psychological distress were considered to have psychological distress Score of 7 out of a possible 24

13. Independent Variables (2) Health insurance status –Examined whether mothers had any health insurance versus none Usual source of care –Measure of continuity (Starfield 1998) –Two level variable Has usual source of care and gets care from clinic, health center, doctor's office, HMO, hospital outpatient department or some other place Does not have usual source of care

14. Dependent Variable “About how long has it been since your last general physical exam or routine checkup by a medical doctor or other health professional?”

15. Dependent Variable Responses included: –Never –A year ago or less –More than 1 year but not more than 2 years –More than 2 years but not more than 3 years –More than 3 years but not more than 5 years –Over 5 years ago

16. Dependent Variable Analysis excludes mothers who reported “never” receiving routine care Modeled the odds of mothers having received routine care 2 or more years ago (this was considered “delayed” care) –Against mothers who received care as recently as a year ago or less, but not more than 2 years

17. Control Variables Maternal age Education Race/ethnicity Health status Current pregnancy status Single parent status Poverty threshold level Region of family residence

18. Results

19. Sample Characteristics 12.8% of mothers reported psychological distress Mothers with distress were more likely to be between the ages of 18-24, have a lower level of education, Hispanic, a single parent, and living in poverty compared with other mothers –No bivariate differences by region of US or whether they were currently pregnant

20. Mothers’ Health Insurance and Usual Source of Care Status, by Psychological Distress Mother have distress? YesNo Health Insurance Status* Has health insurance76.885.0 Does not have health insurance23.215.0 Usual Source of Care (USC)* Has USC and gets care from clinic, health center, Doctor's office, or HMO 83.990.6 No USC16.19.4 *p-value <0.05

21. Mothers Receiving Delayed Routine Care, by Distress Status % Receiving Delayed Routine Care* *p-value <0.05

22. Odds* of Delayed Routine Care for Mothers *Controlling for maternal age, education, race/ethnicity, pregnancy status, single parent status, poverty threshold level, and region of family residence

23. Odds of Delayed Routine Care: Interaction of Usual Source of Care and Maternal Psychological Distress Status Odds of Delayed Routine Care Maternal Psychological Distress Status Mothers without Distress Mothers with Distress Usual Source of Care (USC)* Has usual source of care and gets care from clinic, health center, doctor's office, HMO, hospital outpatient department, or some other place 1.0 (reference category) 1.1 (0.8-1.4) No USC2.8* (2.2-3.6)5.7* (3.7-8.8) *p-value <0.05

24. Summary Conclusions (1) After controlling for potential confounders, maternal psychological distress and not having health insurance or a usual source of care were associated with delayed routine care for mothers Mothers with psychological distress and an appropriate usual source of care (USC) were no more likely to delay a general physical exam than other mothers

25. Summary Conclusions (2) However, mothers with distress and without a USC are nearly 6 times more likely to delay a physical exam –this is significantly higher than non-distressed mothers without a USC (indicating an interaction)

26. Strengths National probability sample First study to examine correlates of the use of routine care for mothers in the context of psychological distress

27. Limitations Timing of the relationship between usual source of care and report of receiving routine care –We examined correlations not causation –Individuals who use more care are more likely to report having a usual source of care

28. Policy Implications Need for USC for mothers with psychological distress These mothers are likely to go unscreened for important preventable and treatable conditions, including mental health problems Significant implications for the long-term health and well-being of mothers and their children