Our study found that 7.25% of CSHCN who needed care from a specialist did not receive it. This exactly matches the study by Mayer et al. (2004) [8
] who also analyzed data from the National Survey of Children with Special Health Care Needs, 2000 – 2002. The current research, however, differs from that of Mayer et al. by examining each of three SES strata independently and then comparing how various risk factors affect each stratum. Mayer et al. (2004) included three levels of SES (< 100% of FPL, 100 – 199% of FPL, and ≥ 200% of FPL) as a factor in the model, thus, controlling for SES.
The current analysis revealed that age is a significant risk factor of having received all needed care from a specialist, but only in the ≥ 300% of FPL stratum. Older children were more likely to have received needed specialty care. One possible explanation is that the disability or need for extra care may not be apparent until the child is older and either enters school or is observed in group settings with other children their age. However, the positive odd ratio for age was relatively small for this group.
The severity of the condition (0 – 10 scale) only demonstrated a significant effect on receiving all needed care from a specialist in the 200 – 299% of FPL stratum, demonstrating that as the severity of the condition increased, the likelihood of having received all needed care decreased.
Our study did find a significant association for ethnicity. When stratified by SES a significant association for Hispanic children was discovered in the < 133% of FPL stratum. The association was positive but not significant for the higher income groups. Our finding of a relationship may be explained by differences in perceived needs and expectations of providers between Hispanic and non-Hispanic parents of CSHCN [16
]. Further research into how these expectations may differ with SES would help explain this interesting finding.
Maternal education significantly affected having received all needed care from a specialist in the 200 – 299% of FPL and ≥ 300% of FPL strata. For CSHCN in the 200 – 299% of FPL stratum, a maternal education of less than or equal to a high school diploma or GED increased the likelihood of having received all needed care as compared to having a four year college degree or more. This is reverse from what would be expected and what was found in the ≥ 300% of FPL stratum. In the highest SES stratum, a lower maternal education was negatively associated with having received all needed care. One explanation for this finding could be that women in the lower SES stratum who are also less educated may have less knowledge of which specialty services could benefit their special needs child and perhaps a lower expectation of the health care system. An appropriate response to this finding would be to increase the efforts to properly educate these mothers regarding the benefits of specialty care. This association, though, was only significant for having some college, but not a four year college degree. The importance of maternal education was not identified when the analysis was not stratified by SES.
Being uninsured and type of health insurance are generally considered factors that affect unmet health care needs for CSHCN. In our study, this association did not present across all SES strata. Being uninsured only significantly predicted having received all needed care in the 133 – 199% of FPL stratum. No significant differences were found for publically and privately insured children. Previous research from the National Survey of Children with Special Health Care Needs, 2000 – 2001 demonstrated that CSHCN who did not meet 3 health insurance components of coverage, continuity, and adequacy demonstrated a greater than three times odds of having one or more unmet health care needs [17
]. Mayer et al. (2004) also found that CSHCN who were uninsured at some point in the past 12 months less likely to have received all needed care from a specialist.
The geographical location of the household played a small role in having received all needed care from a specialist, particularly in the highest income group. For these children living in the Midwest was positively associated with receiving specialty care and the association was significant. Regional differences in availability of specialists to uninsured and Medicaid vs. other public and privately insured children is an issue which warrants further investigation[18
Family structure is important for Children with Special Health Care Needs. The number of adults in the household was positive and significant in the lowest income group. As the number of adults in the household increased, the likelihood of having received all needed care increased. It is especially important in the lower SES strata to have family support with providing care for CSHCN. These poorer families may have additional financial barriers to accessing specialty care such as finding affordable child care for other children to facilitate specialty appointments [19
]. The number of kids in the household significantly predicted having received all needed care in the < 199% of FPL stratum. The coefficients for all income groups were negative, suggesting that the number of kids in the households reduced the likelihood of receiving needed specialty care in poor families. One possible explanation is that when there are more children, there is less time to dedicate to the needs of the CSHCN and the barrier mentioned above regarding child care.