Access to and use of asthma health services among Latino children: the Rhode Island-Puerto Rico asthma center study.

Abstract

This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.

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DOI: 10.1177/1077558711404434
2011 68: 683 originally published online 2 May 2011Med Care Res Rev
Gregory K. Fritz, Sheryl J. Kopel, Ronald Seifer, Robert B. Klein and Glorisa Canino
Barbara Jandasek, Alexander N. Ortega, Elizabeth L. McQuaid, Daphne Koinis-Mitchell,
Rhode Island-Puerto Rico Asthma Center Study
Access to and Use of Asthma Health Services Among Latino Children : The


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34 MCR68610.1177/1077558711404434Jandasek et al.Medical Care Research and Review
This article, submitted to Medical Care Research and Review on September 18, 2009, was revised and
accepted for publication on February 23, 2011.
1Warren Alpert Medical School of Brown University, Providence, RI, USA
2University of California, Los Angeles, Los Angeles, CA, USA
3University of Puerto Rico, San Juan, Puerto Rico
Corresponding Author:
Barbara Jandasek, PhD, Bradley Hasbro Children’s Research Center, Coro West, Suite 204, 1 Hoppin
Street, Providence, RI 02903, USA
Email: bjandasek@lifespan.org
Access to and Use of
Asthma Health Services
Among Latino Children:
The Rhode Island-Puerto
Rico Asthma Center Study
Barbara Jandasek1, Alexander N. Ortega2,
Elizabeth L. McQuaid1, Daphne Koinis-Mitchell1,
Gregory K. Fritz1, Sheryl J. Kopel1, Ronald Seifer1,
Robert B. Klein1, and Glorisa Canino3
Abstract
This study determines asthma-related health care access and utilization patterns for
Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI)
and Latino children residing in Puerto Rico (Island). Data included 804 families of
children with persistent asthma recruited from clinics. Island children were less likely
to receive regular asthma care and care from a consistent provider and more likely to
have been to the emergency department and hospitalized for asthma than RI children.
Island children were 2.33 times more likely to have used the emergency department
for asthma compared with RI non-Latino White (NLW) children. Latino children
residing in both Island and RI were less likely to have used specialty care and more
likely to have had a physician visit for asthma in the past year than RI NLW children.
The differences might reflect the effects of the different delivery systems on pediatric
health care utilization and asthma management.
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Medical Care Research and Review 68(6)
Keywords
asthma, Hispanic Americans, Latino, children, health service accessibility, health care
utilization, Puerto Rico
Childhood asthma continues to be an important clinical and public health problem in
the United States. Data from the National Health Interview Survey show that approxi-
mately 8.5% of children have parent-reported asthma in the United States (Mannino
et al., 2002). It has been estimated that among children, mainland Puerto Ricans have
the highest prevalence of asthma (Carter-Pokras & Gergen, 1993; Lara, Akinbami,
Flores, & Morgenstern, 2006) and asthma-related morbidity rates compared with
Whites, Blacks, or other Latinos (Homa, Mannino, & Lara, 2000). For example, Lara
et al. (2006) used 1997-2001 National Health Interview Survey data and reported that
26% of Puerto Rican children had parent-reported asthma compared with 13% for
non-Latino White (NLW), 16% for non-Latino Black, 10% for Mexican, and 15%
for both Cuban and Dominican children. Children in Puerto Rico (PR) have even
higher parent-reported asthma prevalence rates than mainland Puerto Rican children,
with studies showing lifetime rates as high as 30% to 40% (Ortega et al., 2003; Ortega,
Huertas, Canino, Ramirez, & Rubio-Stipec, 2002; Perez-Perdomo, Perez-Cardona,
Disdier-Flores, & Cintron, 2003).
While researchers have posited that certain factors, mainly biological, environmen-
tal, and psychosocial, may be attributable to asthma-related burden in Puerto Rican
children (Canino et al., 2006; Cohen & Celedon, 2006; Salari & Burchard, 2007), few
studies have focused specifically on health care access and utilization among this group
(Cabana, Lara, & Shannon, 2007; Cohen et al., 2006; Stingone & Claudio, 2006; Ortega,
Huertas, et al., 2002). Additionally, studies have not investigated whether factors beyond
ethnicity may account for any observed differences in health care access and utiliza-
tion patterns in children from Latino and NLW backgrounds. For example, it may be
that factors related to place of residence, poverty, or insurance coverage, independent
of ethnicity, may be implicated in observed differences. A study using the 2000 Behavioral
Risk Factor Surveillance System found that 33% of 4,206 adults interviewed in PR
reported that they had a child with asthma. Of those children with parent-reported
asthma, only 51% were currently in treatment for asthma, 52% made at least one visit
to the emergency department (ED) in the past year, and 27% had at least one hospi-
talization in the past year (2% had 4 or more hospital admissions in the past year;
Perez-Perdomo et al., 2003).
On the U.S. mainland, a cross-sectional study of 5,250 students in 26 New York
City elementary schools found that 22.1% of Puerto Rican, 7.5% of Dominican, and
8.3% of White children had parent-reported current asthma. Indicators of asthma
health care utilization were higher among the Latino groups. Fifty-five percent of
Puerto Rican and 57% of Dominican children in the sample had an ED visit or hospi-
talization in the past 12 months compared with 21.5% of White children. Furthermore,
compared with White children, Puerto Rican children were six times and Dominican
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Jandasek et al.
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children were three times more likely to have been to the ED or hospitalized than NLW
children in the past 12 months (Stingone & Claudio, 2006). In an intervention study of
publicly insured children with asthma in Connecticut, Puerto Rican children had more
outpatient clinic visits and slightly more medication use than African American chil-
dren, but they had fewer hospital days. No differences were observed in rates of ED
visits or hospitalizations, after adjusting for asthma severity, medication use, and other
confounding factors (Cohen et al., 2006). A separate study of children with asthma in
Connecticut showed that Latino children, who were primarily Puerto Rican, had worse
access to care, less use of health services, and poorer asthma management than NLW
children (Ortega, Belanger, Paltiel, et al., 2001; Ortega, Gergen, et al., 2002).
New Contribution
What previous asthma services studies of Latino children fail to show are the follow-
ing: (a) how do access and utilization patterns differ by site (e.g., island vs. mainland)
and ethnic group (e.g., mainland Latino and NLW and island Latino) and (b) whether
predisposing (e.g., age, English proficiency), enabling (e.g., family poverty level,
insurance status), and need (e.g., parent-rated severity) factors (Andersen, 1995;
Gelberg, Andersen, & Leake, 2000) account for any differences in health care use for
Latinos on both the island and mainland. This investigation can further inform our
understanding of asthma disparities among Latinos, thereby informing necessary
intervention. Data from the Rhode Island-Puerto Rico Asthma Center study, a clinic-
based study of children with asthma from Rhode Island (RI) and PR, offer the unique
opportunity to examine the health care access and utilization patterns of Puerto Rican,
Dominican, and NLW children. Rhode Island-Puerto Rico Asthma Center includes
Dominican children because they have also demonstrated high rates of parent-reported
asthma as well as high rates of ED and hospitalization use (Lara et al., 2006; Stingone
& Claudio, 2006). Children with asthma of Dominican background represent an
understudied group; however, similar to Puerto Rican children, Dominican children
with asthma are of Caribbean-origin and often face socioeconomic challenges that
may impinge on their health status and access to care (Hernandez, 1997). Furthermore,
inclusion of children both from the mainland as well as from PR may refine our under-
standing of the relative contribution of contextual versus individual factors associated
with health care behavior and outcomes.
Conceptual Framework
The conceptual framework for this study is the behavioral model developed by Aday
and Andersen (1974) and Andersen (1995). This model hypothesizes that health care
access and utilization are determined by predisposing, enabling, and need factors. Our
empirical analyses use this framework to guide model specification. Thus, predispos-
ing factors in our models include characteristics such as child’s gender and age, place
of birth (island vs. mainland), and parent’s English proficiency. Enabling factors include
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Medical Care Research and Review 68(6)
health insurance coverage, type of health insurance, and poverty threshold. Need is
captured by parent-rated asthma severity.
Study Questions
In this study, we sought to determine (a) whether there were differences in asthma-
related health care access and utilization between island Puerto Rican and mainland
Puerto Rican and Dominican groups compared with mainland NLWs and (b) whether
there were differences in health care access and utilization between island Puerto
Ricans and mainland Puerto Ricans and Dominicans, after adjusting for predisposing,
enabling, and need factors.
Data and Method
Study Design and Sampling
The sample was composed of 804 children aged between 7 and 15 years, with 405
from PR and 399 from RI. Among the children from RI, 112 were Puerto Rican, 136
were Dominican, and 151 were NLW. Participants in RI came primarily from conve-
nience samples recruited at ambulatory pediatric clinics of a hospital and community
primary care clinics. Children were also recruited from a hospital-based asthma edu-
cational program, health fairs and other community events, schools, and various grass-
roots sources (e.g., word of mouth, flyers, 13%). Participants recruited from medical
versus nonmedical sources did not differ on health care variables being investigated
in this current study. In PR, most of the children were recruited from four independent
provider organizations and two ambulatory pediatric clinics from two hospitals, serv-
ing mostly medically indigent patients. To recruit middle to upper income children
with asthma, 29.4% of the sample was recruited from 26 private practice pediatric
offices. The study design was the same in both sites and for all the aims of the study:
a cross-sectional, observational approach with repeated measurements (four sessions
across a 4-month period) of selected variables.
Data Collection
Information was collected in face-to-face interviews with children and their primary
caretakers. Questionnaires and verbal procedures used among the Spanish-speaking
families were translated and adapted from English using multistage, state-of-the-art
methods used previously by the Puerto Rican team of investigators (Canino et al.,
2002; Matias-Carrelo et al., 2003).
The protection of human subjects was approved by the institutional review boards
of the University of Puerto Rico and Rhode Island Hospital. Informed consent and
assent was obtained from both parents and children who participated.
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Asthma Diagnosis
The diagnosis of asthma was determined at both sites by pediatric asthma specialists
based on national (National Asthma Education and Prevention Program, 2007) and
international (Global Initiative for Asthma, 2002) asthma guidelines. Study clinicians
from both PR and RI participated in a series of telephone conference calls to calibrate
assessments across and within sites.
Predictor Variables
We administered measures assessing predisposing, enabling, and need variables.
The predisposing measures were child’s gender and age, place of birth (island vs.
mainland), and parent’s English proficiency. Participants were asked to rate their
ability to read, write, and speak in English on a 4-point Likert-type scale (e.g., 1 =
Not at all to 4 = Excellent; Felix-Ortiz, Newcomb, & Meyer, 1994). The enabling
measures were poverty threshold, an income-to-needs quotient determined by the
yearly household family income by poverty threshold based on family size (Duncan
& Brooks-Gunn, 1997; U.S. Department of Health and Human Services, 2005), insur-
ance coverage in the past 12 months (yes, no), and type of insurance (private, public,
both, neither). The measure of insurance coverage was dichotomized. Specifically,
participants were asked “How much of the past 12 month was your child covered
by any type of health insurance, including Medicaid?” Responses included “all
year,” “most months,” “only a few months or weeks,” and “never.” Responses indi-
cating insurance coverage for “most months” or more were categorized as “yes,”
and “only a few months or weeks” to “never” as “no.” The need measures included
parent-rated severity (very mild to mild, moderate, and severe to very severe). We
included parent-rated severity as our indicator of need (vs. clinician-rated severity),
because we believed it would be more closely related to parental decision making
regarding health care utilization.
Access and Utilization
Access to primary care for asthma treatment is important. Effective outpatient man-
agement of asthma may prevent unnecessary ED visits or hospitalizations. For more
complex cases, asthma specialty care may be necessary. Frequent use of emergency
services suggests poorly controlled asthma. Asthma-related health care access and
utilization questions used in the current study also have been used in previously pub-
lished studies (Ortega, Belanger, Bracken, & Leaderer, 2001; Ortega, Belanger,
Paltiel, et al., 2001; Ortega, Gergen, et al., 2002). The access to asthma care questions
were the following: (a) does the child receive regular asthma care (yes, no); (b) if yes,
where (e.g., private doctor’s office); and (c) does the child receive asthma care from
consistent provider (yes, no). The utilization measures were the following: (a) has the
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Medical Care Research and Review 68(6)
child had a primary care visit for asthma in the past 12 months (yes, no); (b) if yes,
how many visits; (c) has the child had any asthma specialty care in the past 12 months
(yes, no); (d) if yes, how many visits; (e) has the child ever been hospitalized for
asthma (yes, no); (f) has the child been hospitalized for asthma in the past 12 months
(yes, no); (g) has the child visited the ED for asthma in the past 12 months; and (h) if
yes, how many visits.
Statistical Analyses
Chi-square and F-test analyses were used to compare island Puerto Ricans and
Latino and NLWs from RI by the predisposing, enabling, and need factors. Next, we
compared the island Puerto Ricans and mainland Latino and NLWs on access to
care (e.g., having a consistent asthma care provider) as well as on measures of
health care utilization (e.g., number of ED visits for asthma in the past 12 months).
Pairwise comparisons were conducted using Tukey’s honestly significant difference
test and chi-square tests for continuous and dichotomous data, respectively. Finally,
we conducted multiple logistic regressions for dichotomous outcomes and ordinary
least square regression for continuous outcomes to compare health care access and
utilization across groups. Because of the limited power, only factors with the highest
degree of theoretical relevance were controlled for and entered simultaneously into
the multiple regression model. For analyses comparing health care access, we
controlled for child age, child gender, poverty threshold, health insurance coverage,
and parent-rated severity. Given group differences in access to regular asthma care
and its potential impact on asthma care utilization patterns, we included this vari-
able (i.e., “has a place for regular asthma-related care”) in addition to the above
variables for these analyses. Analyses were conducted first on the entire sample
using mainland NLWs as the reference group and second within the Latino group
using mainland Latinos as the reference group. Missing data ranged from 12 to 22
cases and 9 to 18 cases for analyses conducted on the entire sample and Latino
groups, respectively. Sample sizes for subsequent analyses on the entire sample
were 782 to 792; sample sizes for analyses including only Latinos from PR and RI
ranged from 635 to 644.
Results
Table 1 summarizes the differences in predisposing, enabling, and need factors across
the PR and RI Latino and NLW groups. In terms of the predisposing factors, there
were more females among the RI Latinos than NLWs (48.0%, 35.1%). Children and
caregivers reported higher levels of English proficiency among the RI Latinos com-
pared with the island PR children. Results from the analyses examining enabling
factors demonstrated that fewer Latino families (island PR 34.6%; RI Latino 40.7%)
were above the poverty threshold in comparison to NLW families (85.4%). A higher
percentage of RI NLW children had private insurance (61.7%) compared with island
PR (40.0%) and RI Latino (8.9%) children. In terms of need factors, parent ratings of
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Table 1. Demographics and Characteristics of Sample
Rhode Island
Total Sample (N = 804)a
Puerto Rico
(A; n = 405)
Latino
(B; n = 248)
NLW
(C; n = 151)
Overall
p Valueb
Pairwise
Comparisons
Predisposing factors
Female
Child age (SD)
Child ethnicity
White
Puerto Rican
Dominican
U.S. mainland born
Child
Caregiver
English proficiency
Child (SD)
Parent (SD)
Enabling factors
Above poverty
threshold
Insurance coverage
majority of past
12 months
Type of insurance
Private only
Public only
Both
Neither
Need factors
Parent-rated asthma
severity
Very mild to mild
Moderate
Severe to very
severe

44.0%
10.68 (2.51)
48.0%35.1% .04
.81
<.01
B > C*
ns

A, B < C***
A > B > C***
A, C < B***

B < C***
A < B < C***

A < B***
A < B**

A, B < C***
10.63 (2.47)10.52 (2.59)
0% 0%
45.2%
54.8%
100%
0%
0%
100%
0%
—78.6%
19.0%
99.3%
95.4%10.1%
<.01
2.13 (0.72)
2.01 (0.81)
3.40 (0.55)
2.24 (0.96)
—
—
<.01
<.01
34.6%40.7% 85.4%
<.01
96.0%97.6%98.7%.23
ns

40.0%
52.1%
3.2%
4.7%
8.9%
77.3%
10.9%
2.8%
61.7%
30.2%
6.7%
1.3%
<.01
<.01
<.01
.13
C > A > B***
C < A < B***
A < B***
ns

A > B > C**
<.01
19.3%
43.1%
37.6%
25.4%
51.2%
23.4%
49.3%
45.3%
5.4%



Note: NLW = non-Latino White; SD = standard deviation.
a. There was a total of 804 participants; because of missing data, some variables had fewer than 804
participants.
b. χ2 or F test.
*p < .05. **p < .01. ***p < .001.
asthma severity indicated that island PR children had the highest percentage with
severe to very severe asthma (37.6%) compared with RI NLW (5.4%) and RI Latino
(23.4%) children.
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Medical Care Research and Review 68(6)
Table 2. Health Care Access and Utilization for Asthma
Rhode Island

Puerto
Rico (A) Latino (B) NLW (C)
Overall
p Valuea
Pairwise
Comparisons
Health care access
Has a place for regular
asthma-related care
Location of usual asthma-
related care
Private physician’s office
Emergency department
Community health clinic
Hospital clinic/walk-in
clinic/urgent care center
Receives asthma care from
consistent provider
Health care utilization
Physician visit, past
12 months
Number of physician
visits, past 12 months (SD)
Asthma specialty care, past
12 months
Number of visits for
asthma specialty care,
past 12 months (SD)
Ever hospitalized
Hospitalized, past
12 months
Visited ED, past 12 months
(SD)
Number of ED visits, past
12 months (SD)

78.8%97.2% 98.7%
<.01A < B, C***

44.0%
52.3%
14.8%
33.6%
54.9%
34.6%
18.3%
35.4%
75.8%
32.9%
7.5%
24.5%
<.01
<.01
.01
.07
A < B < C**
A > B, C***
A, B > C*
ns
71.1%81.0%85.9%
<.01 A < B, C**

94.3%92.3%81.1%
<.01A, B > C**
5.11 (5.26)4.00 (6.71) 2.82 (2.83)
<.01 A > B, C*
16.1% 14.2%31.1%
<.01 A, B < C***
0.51 (1.58)0.92 (5.35)0.93 (1.93).21
ns
62.0%
23.7%
42.3%
8.9%
32.2%
7.3%
<.01
<.01
A > B > C*
A > B, C***
58.6% 25.4%24.3%
<.01A > B, C***
1.77 (2.62) 0.49 (1.19) 0.42 (1.38)
<.01A > B, C***
Note: NLW = non-Latino White; SD = standard deviation; ED = Emergency department.
a. χ2 or F test.
*p < .05. **p< .01. ***p < .001.
Table 2 compares health care access and utilization across the sites and groups.
A higher percentage of parents of children from RI reported having a regular place for
“breathing problems” (RI NLW 98.7%; RI Latino 97.2%) than parents of island PR
children (78.8%). Furthermore, RI NLW children were more likely to have their regu-
lar asthma care in a private physician office (75.8%) than island PR (44.4%) or RI
Latino (54.9%) children. Island PR children were more likely to have their regular
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691
asthma care in the ED (52.3%) compared with RI NLW (32.9%) and RI Latino (34.6%)
children. Finally, a lower percentage of island PR children had a consistent asthma
provider (71.1%) than RI NLW (85.9%) and RI Latino (81.0%) children.
Table 2 also shows the results for the health care utilization measures. More Latino
children had visited a physician in the past 12 months (Island PR 94.3%; RI Latino
92.3%) compared with RI NLW (81.1%) children. Island PR children had the most
physician visits (M = 5.11) in the past 12 months compared with the other two groups
(RI NLW M = 2.82; RI Latino M = 4.00). A higher percentage of RI NLW children had
received asthma specialty care in the past 12 months (31.1%) compared with island PR
(16.1%) and RI Latino (14.2%) children. A higher percentage of island PR children
had ever been hospitalized for asthma (62.0%), followed by RI Latino children
(42.3%), and RI NLW children (32.2%). Also, a greater percentage of island PR chil-
dren had been hospitalized within the past year for asthma (23.7%) compared with RI
NLW (7.3%) and RI Latino (8.9%) children. Finally, a higher percentage of island PR
children had visited the ED for asthma in the past 12 months (58.6%) compared with
RI NLW (24.3%) and RI Latino (25.4%) children. Island PR children also had the
most ED visits in the past year (M = 1.77; RI Latino M = 0.49; RI NLW M = 0.42).
Table 3 shows the multiple regression results for the health care access and utiliza-
tion measures for both RI Latino and island PR children when compared with RI NLW
children (reference group). Children living in PR were less likely to have an identified
place for regular asthma related care (OR = .09; 95% confidence interval [CI] = 0.02,
0.39). RI Latino children were more likely to have had a physician visit (OR = 2.15;
95% CI = 1.06, 4.36) for asthma but were less likely to have used asthma specialty care
in the past 12 months (OR = 0.39; 95% CI = 0.22, 0.68) than RI NLW children. Island
PR children were more likely to have had a physician visit for asthma (OR = 2.63; 95%
CI = 1.29, 5.35), had a higher mean number of visits (β =.17, p < .01), and were less
likely to have used asthma specialty care (OR = .50; 95% CI = 0.30, 0.84) in the past
12 months than RI NLW children. Island PR children were also more likely to have
visited the ED (OR = 2.33; 95% CI = 1.43, 3.79) for asthma and had a higher mean
number of ED visits in the past 12 months than RI NLW children (β = .17, p < .01).
Island Puerto Ricans Versus Mainland Latinos
Table 4 shows regression analyses comparing island PR children with RI Latino chil-
dren (reference group) on the health care access and utilization measures. Island PR
children were found to differ from RI Latino children on both access measures. They
were less likely to have an identified place for regular care (OR = 0.11; 95% CI =
0.05−0.24) and a consistent care provider (OR = 0.64; 95% CI = 0.43−0.95) for
asthma. Island PR children had more visits to a physician for asthma (β = .08, p < .05)
than RI Latino children. In addition, island PR children were more likely to have been
to the ED (OR = 3.74; 95% CI = 2.55, 5.49), had more ED visits (β =.23, p < .001),
and were more likely to have been hospitalized (OR = 2.73; 95% CI = 1.60, 4.67) for
asthma in the past 12 months than RI Latino children.
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Medical Care Research and Review 68(6)
Discussion
Poor asthma-related health care access and utilization for Latinos of Puerto Rican and
Dominican descent have been documented (Canino et al., 2006; Cohen et al., 2006;
Ortega & Calderon, 2000; Ortega, Gergen, 2002; Stingone & Claudio, 2006). The
current study is a preliminary investigation of factors that may contribute to the ethnic
differences in health care access and utilization. Thus, the current study sought not
only to document health care disparities between ethnic groups (i.e., Latinos vs. NLWs)
but also investigate how these differences vary based on place of residence (e.g.,
mainland United States vs. island). Furthermore, we examined whether differences in
health care access and utilization patterns would persist after controlling for predis-
posing, enabling, and need factors.
Table 3. Regressions Predicting Health Care Access and Utilization for Asthma
Variable Model
Rhode
Island NLW
Rhode Island
LatinoPuerto Rico
Health care accessa
Has a place for
regular asthma-
related care
Receives asthma care
from consistent
provider
Health care utilizationc
Physician visit, past
12 months
Number of visits
Asthma specialty
care, past 12
months
Number of visits
Hospitalized, past
12 months
Visited ED, past
12 months
Number of visits

Logistic (OR)b
Reference 0.83 (0.17−4.18) 0.09 (0.02−0.39)
Logistic (OR)b
Reference 1.07 (0.58−1.95) 0.67 (0.38−1.19)

Logistic (OR)b
Reference2.15 (1.06−4.36) 2.63 (1.29−5.35)
OLS (coefficient)d
Logistic (OR)b
Reference
Reference
0.07 (p = .17)
0.39 (0.22−0.68) 0.50 (0.30−0.84)
0.17 (p < .01)
OLS (coefficient)d
Logistic (OR)b
Reference
Reference
0.00 (p = 1.0)
0.72 (0.32−1.63) 1.96 (0.94−4.09)
−.06 (p = .28)
Logistic (OR)b
Reference0.62 (0.37−1.05) 2.33 (1.43−3.79)
OLS (coefficient)d
Reference −.08 (p = .11) 0.17 (p < .01)
Note: NLW = non-Latino white; OR = odds ratio; OLS = ordinary least squares; ED = emergency
department.
a. Adjusted for child age, child gender, poverty threshold, health insurance coverage, and parent-rated
severity.
b. 95% confidence intervals are presented for odds ratios.
c. Adjusted for child age, child gender, poverty threshold, health insurance coverage, parent-rated
severity, and access to a place for regular asthma-related care.
d. Regression weights are standardized coefficients.
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Asthma is a complex illness, and its presentation is multidetermined and may vary
according to both contextual and individual factors. Understanding mechanisms driv-
ing differences in health care access and utilization is important in informing targeted
interventions, particularly in our attempts to reduce health disparities. This question is
a difficult one to answer given that individual and contextual factors are often con-
founded. It is impossible to completely disentangle the role of various factors, given
the complex nature of factors contributing to asthma’s presentation even within groups
of similar backgrounds. Examining groups of individuals who are similar on the basis
of some characteristics (e.g., ethnicity) but vary with respect to others (e.g., health care
context), however, may refine this understanding.
Overall, the findings of this study support that there are health care access and uti-
lization disparities, both across ethnic groups and within ethnic groups, depending on
place of residence, supporting the potential role of both individual and contextual fac-
tors. Differences in health care access and utilization patterns persisted even after con-
trolling for predisposing, enabling, and need factors. Specifically, Latinos residing in
PR were less likely to report either having an identified place for regular care (compared
with both RI NLW and Latinos residing in RI) or a consistent provider for asthma
Table 4. Regressions Predicting Health Care Access and Utilization for Asthma for Mainland
Versus Island Latinos
VariableModel Rhode Island LatinoPuerto Rico
Health care accessa
Has a place for regular asthma-
related care
Receives asthma care from
consistent provider
Health care utilizationc
Physician visit, past 12 months
Number of visits
Asthma specialty care, past
12 months
Number of visits
Hospitalized in past 12 months
ED visit in past 12 months
Number of visits

Logistic (OR)b
Reference 0.11 (0.05−0.24)
Logistic (OR)b
Reference0.64 (0.43−0.95)

Logistic (OR)b
OLS (coefficient)d
Logistic (OR)b
Reference
Reference
Reference
1.27 (0.64−2.50)
0.08 (p < .05)
1.25 (0.77−2.02)
OLS (coefficient)d
Logistic (OR)b
Logistic (OR)b
OLS (coefficient)d
Reference
Reference
Reference
Reference
-.05 (p = .20)
2.73 (1.60−4.67)
3.74 (2.55−5.49)
.23 (p < .001)
Note: NLW = non-Latino white; OR = odds ratio; OLS = ordinary least squares; ED = emergency
department.
a. Adjusted for child age, child gender, poverty threshold, health insurance coverage, and parent-rated
severity.
b. 95% confidence intervals are presented for odds ratios.
c. Adjusted for child age, child gender, poverty threshold, health insurance coverage, parent-rated
severity, and access to a place for regular asthma-related care.
d. Regression weights are standardized coefficients.
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Medical Care Research and Review 68(6)
(compared with Latinos residing in RI). Latinos residing in both PR and RI were more
likely to receive asthma care from a primary care physician and less likely to receive
care from a specialist compared with NLWs. Latinos residing in PR demonstrated
higher utilization, in terms of asthma-related physician and ED visits, than both
Latinos and NLWs residing in RI; these high utilization rates were observed after
accounting for multiple confounding factors. They were also significantly more likely
to receive asthma care from the ED than both the other groups, and compared with RI
Latinos, they were more likely to be hospitalized. These findings were particularly
interesting given that in our clinic sample of island Puerto Rican children, 40% had
private insurance and 52% had public insurance compared with 77% of RI Latino
children having public insurance and 9% having private insurance. However, it is pos-
sible that island participants may have overreported private insurance because Medicaid
is managed by independent practice groups.
An interesting consideration related to individual factors is the role of parent’s per-
ceptions of their child’s asthma severity in making decisions regarding health care
utilization. Parents’ perceptions of their children’s levels of severity may contribute to
utilization behaviors, particularly for ED and primary care use. For example, if a parent
does not perceive her child to have moderate or severe asthma, then she may be less
assertive in making a primary care appointment for asthma. Alternatively, if a parent
perceives her child to have very severe asthma, she may be more inclined to use the
ED. Differences in parental perception and asthma beliefs may partially explain higher
utilization patterns among Latino families. It should be noted, however, that reported
differences in hospitalization rates reflect physician, as opposed to parental, decision
making. Thus, an interesting area for future inquiry is to explore the associations between
parental and clinician ratings, with the use of objective measures, and to determine their
influences in health care seeking decisions. In addition, understanding the determi-
nants of parental severity estimation, such as parental worry, fear and disease knowledge,
and parent–child communication regarding symptoms, would be useful in understanding
the motivators for health care utilization.
Findings from the current study also indicate the potential role of contextual factors
in health care access and utilization patterns. Island children were found to have lower
access to regular asthma care and higher rates of ED use, even after controlling for
individual factors, such as parent-rated asthma severity and socioeconomic status,
than both groups of mainland children. The health care systems between PR and RI are
different, in terms of delivery, accessibility, and financial arrangements, especially for
those children receiving public insurance. For example, in PR, individuals of low
socioeconomic status are covered under an island-wide program partly funded by
Medicaid in which families are not required to pay for covered medication. There is a
disproportionate high enrollment of Puerto Rican children in public health plans, since
approximately 42% of families live below the poverty level (Guzman, 2001), which
makes them eligible for the island-wide Puerto Rican Public Health Plan. Under this
system, the government contracts with managed care organizations (MCOs) by a negoti-
ated capitation payment. The MCOs then contract with provider groups (e.g., independent
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provider associations), and many of these subcontracts pass financial risk for treat-
ment cost down to primary care provider groups. Under the current policy, primary
care providers are directly financially responsible for medication costs and referrals
to specialists.
While such arrangements are sometimes observed in the states (e.g., MCO MediCal
subcontracts to physician groups in California), the capitation levels in PR are much
lower so that passing the financial risk down to providers constitutes a major barrier to
use of expensive medication. As a result, financial incentives to primary care providers
in PR may discourage them from prescribing inhaled steroids or other expensive
controller therapy. It is possible that the observed low use of controller medication is
attributable to the high use of ED care, where physicians are focused on treating acute
symptoms and not necessarily chronic disease management. Furthermore, in PR,
patients receive free medication in the ED. In addition, none of the outpatient clinics
operate outside of regular office hours and very few are open on the weekends, forcing
many working poor island Puerto Ricans to use the ED to avoid missing work. In con-
trast, in RI, the public health plans operate more similarly to private health plans, in
which physicians bill for office visits, and the plans tend to cover most or all of the
medication costs. Additionally, community health centers have more flexible hours,
including evening and weekend appointments.
Thus, the differences observed between island children and mainland Latino chil-
dren may be related to differences in the health care delivery systems between sites.
While we controlled for important predisposing and enabling factors, the relatively
lower utilization rates among RI Latinos, in terms of number of physician visits for
asthma, also may be a result of system, policy, economic, and geographic barriers that
were not accounted for in this study. It is important to note, however, that RI Latinos
were more likely to receive care in private physicians’ offices, and they were more
likely to identify a regular location for receiving asthma care, and to have a consistent
provider compared with island Puerto Ricans. These may be indicators of good health
care quality and partly explain the lower utilization and ED rates in RI. Conversely, the
health care utilization patterns in PR characterized by higher ED and lower specialty
care utilization rates may be indicative of less optimal management and care of asthma.
As in any observational study, especially those using clinical samples, there are limi-
tations in our findings. First, because of health care/clinic differences between RI and
PR, we were not able to apply equivalent recruitment strategies across sites. The RI site
used a broader range of recruitment sources (e.g., grassroots, educational programs)
that may have introduced some unknown selection biases. Moreover, as our study par-
ticipants in both sites were recruited from clinics and because we did not use a probabil-
ity sampling design, generalization to target populations should be interpreted in the
context of these sampling strategies. We may not have accessed children who were not
receiving any care at all for their asthma. These factors suggest caution in generalizing
our findings to the overall population of children with asthma, particularly those with
the lowest levels of health care access. Finally, there may be additional factors not
directly assessed in this study (e.g., beliefs about asthma, knowledge of health care or
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environmental exacerbation triggers such as tobacco smoke and pet dander) that may
affect access and utilization patterns among the groups examined in this study. Despite
these limitations, however, and given the dearth of health services data on PR and
Dominican children with asthma, groups that have demonstrated high risk, our findings
lend some insight into potential health care disparities experienced by these populations.
Conclusion
Very little research has focused on asthma-related health care access and utilization
patterns for PR and Dominican children, especially for children living in PR. This
study demonstrates that after controlling for predisposing, enabling, and need factors,
island PR children have high health care consumption patterns and are more likely to
receive care in nonprivate settings than Latino and NLW children from RI. Future
research should focus on how the organization of the Puerto Rican primary care system
contributes to high rates of health care utilization and ED use for childhood asthma.
Author’s Notes
The grantors had no involvements in the study design, collection, analysis or interpretation of
data, writing of the manuscript, or the decision to submit the manuscript for publication.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article: This work was supported by the National Heart, Lung and
Blood Institute (Grant U01-HL072438).
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