Psychological Distress and Timely Use of Routine Care: The Importance of Having Health Insurance and

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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

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Other Contributors

• Timothy Ferris, MD
• Lisa Fortuna, MD, MPH
• Robert Kahn, MD, MPH
• Karen Kuhlthau, PhD
• Paul Pirraglia, MD, MPH
• Jonathan Winickoff, MD, MPH

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Structure of Talk

• Background
• Methods
• Results
• Summary conclusions
• Strengths and limitations
• Policy implications

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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)

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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

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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

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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

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

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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

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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

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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?

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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

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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

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Control Variables

• Maternal age
• Education
• Race/ethnicity
• Health status
• Current pregnancy status
• Single parent status
• Poverty threshold level
• Region of family residence

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Results
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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

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Mothers Health Insurance and Usual Source of
Care Status, by Psychological Distress
p-value 21
Mothers Receiving Delayed Routine Care, by
Distress Status
Receiving Delayed Routine Care
p-value 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
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Odds of Delayed Routine Care Interaction of
Usual Source of Care and Maternal Psychological
Distress Status
p-value 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

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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)

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Strengths

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

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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

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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