Article Figures & Data
Figures
- Figure 1.
Model-adjusted prevalence of forgone care experiences of children aged 5 to 12 years by parental experiences of racial discrimination.
Notes: Marginal standardization was used to obtain the model-adjusted prevalence of forgone care by experiences of parental racial discrimination. Logistic regression models adjusted for child’s age, sex, and race/ethnicity. Racial discrimination was measured using a modified version of the Everyday Discrimination Scale and coded using (A) situation-based coding (ie, number of different situations of discrimination ever experienced) and (B) frequency-based coding (ie, sum of responses indicating frequency of discrimination experienced across situations). See Supplemental Table 1 for additional details about operationalization of measures. Gray bands depict 95% CIs. See Table 1 for definition of forgone care.
Tables
Indicator/Construct Question Definition/Response Options Data Source Forgone care Since [month of first survey] 2020, were any health care services, including medical check-up, well- or sick-child visit, or vaccination appointment for [child name] delayed, missed, or not scheduled for any reason?a Coded according to parent response: yes or no CovEx Wave 2 Type of care forgone What health services were delayed, missed, or not scheduled? Sick-child visit; treatment for injury; well-child check-up or sports physical; immunizations; visit concerning child’s development or health in general; mental or behavioral health services; speech therapy, occupational therapy, or physical therapy; substance use treatment; treatment for ongoing illnessb CovEx Wave 2 Reason for forgoing care Did any of the following reasons contribute to [child name] not receiving needed health services? I could not pay; I did not have health insurance for my child; I did not know where to go; I had no transportation; I thought the problem would go away; I found it hard to make an appointment; I was afraid of what the doctor would say or do; I was afraid of catching COVID-19; I couldn’t find a clinic that was openb CovEx Wave 2 Forgone vaccinations or well-child visits What health services were delayed, missed, or not scheduled?a Coded as yes if parent endorsed forgone well-child check-up or sports physical or immunizations CovEx Wave 2 No well-child visit or vaccine-related visit Wave 1: Did [child name] receive the following types of care?
Wave 2: Has [child name] received any of the following health care services since [month of first wave] 2020?Coded as yes if parent did not endorse “in-person well-child visit (including to receive vaccines/immunizations)” at both Wave 1 and Wave 2 CovEx Wave 1 and Wave 2 - Table 2.
Indicators of Unmet Health Care Needs by Child-, Parent-, Household-, and County-Level Characteristics
Characteristica Overall Sample Forgone Care, No. (%) or Median (IQR)b Forgone Vaccinations or Well-Child Visits, No. (%) or Median (IQR)b No Well-Child or Vaccine-Related Visit, No. (%) or Median (IQR)b Yes No P Value’ Yes No P Valuec Yes No P Valuec Total children 1,287 214 (16.3) 1,068 (83.7) … 134 (10.9) 1,148 (89.1) … 382 (30.1) 900 (69.9) … Child level Age group .29 .27 .07 5-8 years 557 (43.1) 93 (14.9) 461 (85.1) 60 (9.6) 494 (90.4) 154 (26.9) 398 (73.1) 9-12 years 729 (56.9) 121 (17.5) 606 (82.5) 74 (11.9) 653 (88.1) 228 (32.7) 501 (67.3) Sex .19 .86 .58 Male 672 (50.6) 118 (18.0) 551 (82.0) 71 (11.1) 598 (88.9) 205 (30.8) 464 (69.2) Female 613 (49.4) 95 (14.6) 516 (85.4) 62 (10.7) 549 (89.3) 176 (29.3) 435 (70.7) Race/ethnicity .05 .006 .81 Non-Hispanic White 795 (52.1) 108 (13.2) 685 (86.8) 63 (8.0) 730 (92.0) 236 (30.6) 556 (69.4) Non-Hispanic Black 129 (10.3) 22 (14.8) 106 (85.2) 13 (8.7) 115 (91.3) 39 (32.1) 88 (67.9) Hispanic 202 (26.3) 46 (21.0) 155 (79.0) 30 (14.3) 171 (85.7) 60 (29.6) 142 (70.4) Non-Hispanic other race or multiracial 153 (11.3) 37 (21.6) 116 (78.4) 28 (19.0) 125 (81.0) 45 (26.3) 108 (73.7) Existing emotional, mental, developmental, behavioral condition <.001 .05 .004 Yes 274 (21.8) 80 (28.0) 193 (72.0) 41 (15.3) 232 (84.7) 60 (21.2) 213 (78.8) No 1,008 (78.2) 132 (13.0) 873 (87.0) 92 (9.7) 913 (90.3) 320 (32.5) 684 (67.5) Existing physical condition <.001 .02 .01 Yes 154 (11.3) 56 (34.4) 98 (65.6) 29 (17.5) 125 (82.5) 34 (19.6) 119 (80.4) No 1,126 (88.7) 156 (13.9) 966 (86.1) 104 (10.0) 1,018 (90.0) 347 (31.5) 775 (68.5) Child covered by health insurance .47 .25 .06 Yes 1,217 (94.6) 204 (16.7) 1,010 (83.3) NRd 1,085 (88.7) 347 (28.7) 867 (71.3) No 60 (5.4) 10 (12.9) 49 (87.1) NRd 54 (93.5) 30 (48.7) 29 (51.3) Experienced racism <.001 .001 .92 Yes 80 (6.2) 30 (43.3) 50 (56.7) 16 (25.2) 64 (74.8) 24 (30.8) 55 (69.2) No 1,203 (93.8) 183 (14.5) 1,017 (85.5) 118 (10.0) 1,082 (90.0) 358 (30.1) 842 (69.9) Mode of school instruction .03 .03 .04 In-person full time or hybride 697 (51.7) 100 (13.1) 596 (86.9) 60 (8.2) 636 (91.8) 201 (30.2) 494 (69.8) Virtual full time 457 (39.7) 87 (19.4) 367 (80.6) 56 (13.2) 398 (86.8) 129 (27.3) 326 (72.7) Other 129 (8.5) 27 (21.8) 102 (78.2) 18 (16.5) 111 (83.5) 52 (43.2) 77 (56.8) Parentf or household level Age group .12 .37 .39 18-29 years 84 (8.8) 22 (24.4) 61 (75.6) NRd 70 (85.5) 24 (24.3) 57 (75.7) 30-44 years 904 (68.1) 144 (14.6) 756 (85.4) 92 (9.6) 808 (90.4) 271 (29.9) 631 (70.1) 45-59 years 258 (21.4) 40 (17.6) 218 (82.4) 25 (13.5) 233 (86.5) 77 (33.9) 181 (66.1) ≥60 years 41 (1.7) 8 (27.8) 33 (72.2) NRd 37 (86.5) 10 (20.0) 31 (80.0) Sex .17 .99 .31 Male 429 (44.6) 58 (14.5) 370 (85.5) 40 (10.9) 388 (89.1) 137 (31.7) 290 (68.3) Female 858 (55.4) 156 (17.8) 698 (82.2) 94 (10.9) 760 (89.1) 245 (28.9) 610 (71.1) Race/ethnicity .16 .04 .37 Non-Hispanic White 886 (55.2) 126 (13.8) 758 (86.2) 78 (8.6) 806 (91.4) 268 (32.5) 616 (67.5) Non-Hispanic Black 128 (11.3) 23 (16.2) 104 (83.8) 14 (9.0) 113 (91.0) 38 (31.9) 88 (68.1) Hispanic 145 (23.1) 33 (20.2) 111 (79.8) 19 (14.1) 125 (85.9) 37 (25.3) 107 (74.7) Non-Hispanic other race or multiracial 128 (10.4) 32 (21.3) 95 (78.7) 23 (18.2) 104 (81.8) 39 (26.1) 89 (73.9) Racial discrimination: frequency-based codingg 5.0 (5.0-9.0) 7.0 (5.0-12.0) 5.0 (5.0-7.0) <.001 8.0 (5.0-11.0) 5.0 (5.0-8.0) <.001 5.0 (5.0-9.0) 5.0 (5.0-8.0) .34 Racial discrimination: situation-based codingh 0.0 (0.0-3.0) 2.0 (0.0-5.0) 0.0 (0.0-2.0) <.001 2.0 (0.0-5.0) 0.0 (0.0-2.0) <.001 0.0 (0.0-3.0) 0.0 (0.0-2.7) .29 Experienced childcare challenges <.001 .009 <.001 Often/sometimes 418 (31.2) 107 (24.4) 309 (75.6) 69 (15.3) 347 (84.7) 104 (23.3) 312 (76.7) Rarely/never 867 (68.8) 107 (12.7) 757 (87.3) 65 (8.9) 799 (91.1) 278 (33.3) 586 (66.7) Household income .29 .57 .10 <$30,000 239 (23.2) 51 (17.8) 187 (82.2) 29 (10.1) 209 (89.9) 78 (30.1) 159 (69.9) $30,000 to <$60,000 327 (27.3) 63 (19.4) 261 (80.6) 38 (13.3) 286 (86.7) 102 (33.0) 224 (67.0) $60,000 to <$100,000 366 (23.3) 47 (13.0) 319 (87.0) 27 (8.7) 339 (91.3) 124 (33.7) 241 (66.3) >$100,000 355 (26.1) 53 (14.8) 301 (85.2) 40 (11.2) 314 (88.8) 78 (23.9) 276 (76.1) County level Ratio of population to primary care physicians 1,375.4 (1,079.0-1,943.4) 1,374.6 (1,111.6-1,909.5) 1,375.4 (1,078.9-1,943.3) .83 1,354.7 (1,084.7-1,946.8) 1,377.3 (1,079.0-1,939.3) .95 1,437.3 (1,144.9-2,059.5) 1,354.3 (1,049.0-1,877.4) .007 Urban-rural classification .27 .08 .002 Urban 406 (33.0) 74 (17.2) 330 (82.8) 44 (11.8) 360 (88.2) 117 (32.0) 288 (68.0) Suburban 581 (44.6) 95 (17.4) 483 (82.6) 65 (12.4) 513 (87.6) 1 52 (23.6) 428 (76.4) Rural 300 (22.4) 45 (12.9) 255 (87.1) 25 (6.6) 275 (93.4) 113 (40.2) 184 (59.8) Residential segregation – Black:White index 52.3 (45.3-62.3) 50.9 (44.4-58.7) 52.3 (45.4-62.7) .28 53.1 (45.3-58.7) 52.3 (45.2-62.4) .87 52.3 (44.5-64.0) 52.3 (45.4-60.4) .92 Percent of people younger than age 18 years in poverty 15.6 (10.8-20.1) 16.3 (10.9-19.9) 15.4 (10.8-20.1) .70 16.0 (10.8-18.5) 15.6 (10.9-20.1) .35 15.8 (10.9-20.5) 15.6 (10.7-19.9) .37 Percent of children younger than age 19 years without health insurance 4.6 (3.5-7.1) 4.5 (3.4-7.1) 4.7 (3.5-7.1) .36 4.4 (3.4-6.5) 4.7 (3.5-7.2) .25 4.6 (3.5-7.1) 4.6 (3.5-7.2) .70 Percent of inpatient beds occupied 72.0 (60.0-80.0) 72.5 (64.0-79.0) 72.0 (60.0-80.0) .68 74.0 (66.6-79.0) 72.0 (60.0-80.0) .21 70.0 (57.0-79.0) 73.0 (61.0-80.0) .05 IQR = interquartile range; NR = not reported.
↵a See Supplemental Table 1 for details regarding measures, survey questions, data sources, and operationalization for characteristics.
↵b Unweighted numbers and weighted percents for categorical characteristics, and medians and interquartile ranges for continuous characteristics.
↵c P values from χ2 tests with Rao and Scott second-order correction for categorical characteristics and from Wilcoxon rank-sum tests for continuous characteristics.
↵d Suppressed because the unweighted count was ≤5, which could lead to disclosure risks. Accompanying cells are also suppressed to prevent back calculations.
↵e Combination of in-person part time and virtual part time.
↵f For the parent who completed the survey.
↵g Possible range of scores is 5-20. Higher scores represent a higher frequency of racial discrimination experienced.
↵h Possible range of scores is 0-5. Higher scores represent a greater number of different situations of racial discrimination experienced.
Note: See Table 1 for indicator definitions.
Measure Children, No. (%) Types of health care forgonea Well-child check-up or sports physical 125 (10.4) Vaccinations 36 (3.2) Sick-child visit 27 (2.3) Mental or behavioral health services 29 (1.8) Visit concerning child’s development 25 (1.8) Speech, occupational, or physical therapy 19 (1.0) Treatment for ongoing illness 14 (0.8) Reasons for forgoing health careb I was afraid of catching COVID-19 78 (38.0) I found it hard to make an appointment 41 (18.6) I had no transportation 16 (7.5) I did not know where to go 13 (7.4) I couldn’t find a clinic that was open 16 (6.9) I could not pay 17 (6.7) I did not have health insurance for my child 10 (5.5) I thought the problem would go away 10 (3.6) I was afraid of what the doctor would say or do 6 (2.6) ↵a Reported for the entire study population of 1,287 children. Types of health care forgone were not mutually exclusive; respondents could indicate multiple types.
↵b Reported for the subset of 214 children (16.3%) whose parents reported that the child had forgone care. Reasons for forgoing health care were not mutually exclusive; respondents could indicate multiple reasons.
Note: See Table 1 for definition of forgone care.
- Table 4.
Adjusted Associations of Child-, Parent-, Household-, and County-Level Characteristics With Indicators of Unmet Health Care Needs
Characteristica Forgone Care, APR (95% CI) Forgone Vaccinations or Well-Child Visits, APR (95% CI) No Well-Child Visit or Vaccine-Related Visit, APR (95% CI) Child level Age group 5-8 years Ref Ref Ref 9-12 years 1.2 (0.9-1.6) 1.3 (0.9-1.9) 1.2 (1.0-1.5) Sex Male Ref Ref Ref Female 0.8 (0.6-1.1) 0.9 (0.6-1.4) 1.0 (0.8-1.2) Race/ethnicity Non-Hispanic White Ref Ref Ref Non-Hispanic Black 1.1 (0.6-1.9) 1.1 (0.5-2.2) 1.1 (0.8-1.5) Hispanic 1.6 (1.1-2.3) 1.8 (1.1-2.9) 1.0 (0.7-1.4) Non-Hispanic other race or multiracial 1.7 (1.1-2.6) 2.4 (1.5-3.9) 0.9 (0.7-1.2) Existing emotional, mental, developmental, behavioral condition Yes 2.1 (1.5-2.8) 1.5 (0.9-2.3) 0.6 (0.5-0.9) No Ref Ref Ref Existing physical condition Yes 2.4 (1.6-3.5) 1.6 (1.1-2.6) 0.6 (0.4-0.9) No Ref Ref Ref Child covered by health insurance Yes 1.3 (0.6-2.7) 1.7 (0.7-4.5) 0.6 (0.4-0.9) No Ref Ref Ref Experienced racism Yes 2.7 (2.0-3.6) 2.1 (1.3-3.5) 1.0 (0.7-1.6) No Ref Ref Ref Mode of school instruction In-person full time or hybrid 0.7 (0.5-1.0) 0.7 (0.5-1.0) 1.1 (0.9-1.4) Virtual full time Ref Ref Ref Parentb and household level Age group 18-29 years 1.6 (1.0-2.6) 1.5 (0.8-2.9) 0.8 (0.5-1.3) 30-44 years Ref Ref Ref 45-59 years 1.2 (0.8-1.8) 1.3 (0.8-2.2) 1.1 (0.8-1.5) ≥60 years 1.9 (0.8-4.2) 1.4 (0.4-4.9) 0.6 (0.3-1.4) Sex Male 0.8 (0.6-1.1) 1.0 (0.7-1.5) 1.1 (0.9-1.3) Female Ref Ref Ref Race/ethnicity Non-Hispanic White Ref Ref Ref Non-Hispanic Black 1.2 (0.5-2.8) 0.9 (0.3-2.2) 0.8 (0.4-1.7) Hispanic 1.1 (0.6-1.8) 1.2 (0.6-2.4) 0.6 (0.4-0.9) Non-Hispanic other race or multiracial 1.3 (0.7-2.3) 1.4 (0.7-2.8) 0.8 (0.5-1.3) Experienced childcare challenges Often/sometimes 1.9 (1.4-2.5) 1.6 (1.1-2.4) 0.7 (0.6-0.9) Rarely/never Ref Ref Ref Household income <$30,000 1.2 (0.7-2.0) 0.9 (0.4-1.8) 1.3 (0.9-1.8) $30,000 to <$60,000 1.3 (0.8-2.0) 1.1 (0.7-1.9) 1.4 (1.1-1.8) $60,000 to <$100,000 0.9 (0.5-1.4) 0.8 (0.4-1.5) 1.4 (1.1-1.9) ≥$100,000 Ref Ref Ref County level Ratio of population to primary care physicians Q1 (greatest access) Ref Ref Ref Q2 1.1 (0.8-1.7) 1.1 (0.7-1.7) 1.3 (1.0-1.7) Q3 1.0 (0.6-1.9) 1.4 (0.7-2.7) 1.4 (1.1-1.8) Q4 (least access) 1.3 (0.8-2.1) 1.0 (0.4-2.5) 1.3 (0.9-1.9) Urban-rural classification Urban 0.9 (0.6-1.3) 0.9 (0.5-1.4) 1.3 (1.0-1.8) Suburban Ref Ref Ref Rural 0.8 (0.6-1.1) 0.6 (0.4-0.9) 1.7 (1.3-2.2) Residential segregation – Black:White index Q1 (least segregation) 1.2 (0.7-2.0) 1.2 (0.6-2.5) 1.2 (0.8-1.7) Q2 1.3 (0.9-1.9) 1.2 (0.7-2.1) 0.8 (0.6-1.1) Q3 1.3 (0.9-1.9) 1.4 (0.8-2.3) 0.7 (0.5-0.9) Q4 (most segregation) Ref Ref Ref Percent of people younger than age 18 years in poverty Q1 (least poverty) Ref Ref Ref Q2 1.2 (0.8-1.8) 1.3 (0.8-2.0) 0.9 (0.7-1.2) Q3 1.2 (0.9-1.8) 0.9 (0.6-1.6) 1.0 (0.7-1.3) Q4 (most poverty) 0.9 (0.5-1.5) 0.5 (0.2-1.2) 1.2 (0.8-1.9) Percent of children younger than age 19 years without health insurance Q1 (least uninsured) Ref Ref Ref Q2 0.8 (0.6-1.2) 0.8 (0.5-1.3) 1.0 (0.7-1.3) Q3 0.8 (0.5-1.2) 0.9 (0.5-1.7) 1.1 (0.9-1.4) Q4 (most uninsured) 1.1 (0.7-1.7) 0.8 (0.4-1.7) 1.0 (0.7-1.4) Percent of inpatient beds occupied Q1 (least occupancy) 0.9 (0.4-1.8) 0.7 (0.3-1.9) 1.4 (1.0-2.0) Q2 0.9 (0.5-1.5) 0.6 (0.3-1.1) 1.4 (1.0-1.9) Q3 1.0 (0.7-1.6) 0.9 (0.5-1.6) 1.1 (0.8-1.5) Q4 (greatest occupancy) Ref Ref Ref APR = adjusted prevalence ratio; Q1 = quartile 1; Q2 = quartile 2; Q3= quartile 3; Q4 = quartile 4.
↵a See Supplemental Table 1 for details regarding measures, survey questions, data sources, and operationalization for all characteristics and indictors of unmet health care needs.
b For the parent who completed the survey.
Notes: We fit separate weighted logistic regression models using predicted marginal standardization to examine associations of each selected independent variable with each of the 3 indicators of unmet health care needs while adjusting for age, sex, and race/ethnicity of the child. See Table 1 for indicator definitions.
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