Differences in Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders Among Children Aged 2-8 Years in Rural and Urban Areas - United States, 2011-2012

Abstract

Problem/condition: Mental, behavioral, and developmental disorders (MBDDs) begin in early childhood and often affect lifelong health and well-being. Persons who live in rural areas report more health-related disparities than those in urban areas, including poorer health, more health risk behaviors, and less access to health resources.

Reporting period: 2011-2012.

Description of system: The National Survey of Children's Health (NSCH) is a cross-sectional, random-digit-dial telephone survey of parents or guardians that collects information on noninstitutionalized children aged <18 years in the United States. Interviews included indicators of health and well-being, health care access, and family and community characteristics. Using data from the 2011-2012 NSCH, this report examines variations in health care, family, and community factors among children aged 2-8 years with and without MBDDs in rural and urban settings. Restricting the data to U.S. children aged 2-8 years with valid responses for child age and sex, each MBDD, and zip code resulted in an analytic sample of 34,535 children; MBDD diagnosis was determined by parent report and was not validated with health care providers or medical records.

Results: A higher percentage of all children in small rural and large rural areas compared with all children in urban areas had parents who reported experiencing financial difficulties (i.e., difficulties meeting basic needs such as food and housing). Children in all rural areas more often lacked amenities and lived in a neighborhood in poor condition. However, a lower percentage of children in small rural and isolated areas had parents who reported living in an unsafe neighborhood, and children in isolated areas less often lived in a neighborhood lacking social support, less often lacked a medical home, and less often had a parent with fair or poor mental health. Across rural subtypes, approximately one in six young children had a parent-reported MBDD diagnosis. A higher prevalence was found among children in small rural areas (18.6%) than in urban areas (15.2%). In urban and the majority of rural subtypes, children with an MBDD more often lacked a medical home, had a parent with poor mental health, lived in families with financial difficulties, and lived in a neighborhood lacking physical and social resources than children without an MBDD within each of those community types. Only in urban areas did a higher percentage of children with MBDDs lack health insurance than children without MBDDs. After adjusting for race/ethnicity and poverty among children with MBDDs, those in rural areas more often had a parent with poor mental health and lived in resource-low neighborhoods than those in urban areas.

Interpretation: Certain health care, family, and community disparities were more often reported among children with MBDDS than among children without MBDDs in rural and urban areas.

Public health action: Collaboration involving health care, family, and community services and systems can be used to address fragmented services and supports for children with MBDDs, regardless of whether they live in urban or rural areas. However, addressing differences in health care, family, and community factors and leveraging community strengths among children who live in rural areas present opportunities to promote health among children in rural communities.

FIGURE 1

Prevalence of selected health care and family factors* among children aged 2–8 years with and without mental, behavioral, and developmental disorders^† in urban and rural areas^§ — National Survey of Children’s Health, United States, 2011–2012 Abbreviations: MBDD = mental, behavioral, or developmental disorder; RUCA = rural-urban commuting area. * Inadequate insurance: Based on a negative response to one of five variables included in the following questions: 1) whether the child has current health insurance coverage; 2) whether the child had gaps in coverage in the past 12 months, 3) whether the coverage is sufficient to meet the child’s needs; 4a) whether the family pays out-of-pocket expenses, and if yes, 4b) whether these expenses are usually or always reasonable; and 5) whether insurance allows the child to see needed health care providers. No medical home: To have a medical home, children must have a personal doctor or nurse, usual source of care, and family-centered care; children needing referrals or care coordination must also have those criteria met. Parent with fair or poor mental health: Based on responses of “fair" or "poor” (i.e., compared with "excellent," "very good," or "good") to questions about maternal and paternal mental health. Maternal question: “In general, what is the status of [child name]’s [mother’s/your] mental and emotional health?” Paternal question: “In general, what is the status of [child name]’s [father’s/your] mental and emotional health?” Financial difficulties: Based on responses of “very often” or “somewhat often” (compared with "rarely" or "never") to “Since [the child] was born, how often has it been very hard to get by on your family’s income, for example, it was hard to cover the basics like food or housing?” ^† Significant differences in the prevalence of health care and family factors were found between children with and without MBDDs in certain urban and rural areas. Inadequate insurance: urban areas; no medical home: urban, small rural, and isolated areas; parent with fair or poor mental health: urban, large rural, small rural, and isolated areas; financial difficulties: urban, large rural, and small rural areas. ^§ Urban and rural designations were determined using the four-category classification of the 2006 RUCAs, a census tract–based classification system. Urban areas (RUCA codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1) include metropolitan areas and surrounding towns from which commuters flow to an urban area; large rural areas (RUCA codes 4.0, 4.2, 5.0, 5.2, 6.0, and 6.1) include large towns (micropolitan areas) with populations of 10,000–49,999 and their surrounding areas; small rural areas (RUCA codes 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.2) include small towns with populations of 2,500–9,999 and their surrounding areas; isolated areas (RUCA codes 10.0, 10.2, 10.3, 10.4, 10.5, and 10.6) are not near towns with a population of ≥2,500. (Source: US Department of Health and Human Services, Health Resources and Services Administration. The health and well-being of children in rural areas: a portrait of the nation 2011–2012. Rockville, MD: US Department of Health and Human Services; 2015. https://mchb.hrsa.gov/nsch/2011-12/rural-health/pdf/rh_2015_book.pdf)

FIGURE 2

Prevalence of selected community factors* among children aged 2–8 years with and without mental, behavioral, and developmental disorders^† in urban and rural areas^§ — National Survey of Children’s Health, United States, 2011–2012 Abbreviations: MBDD = mental, behavioral, or developmental disorder; RUCA = rural-urban commuting area. * Neighborhood with limited amenities: Based on responses of “no” to at least one of the following statements: “Please tell me if the following places and things are available to children in your neighborhood, even if [the child] does not actually use them”: 1) sidewalks or walking paths; 2) a park or playground area; 3) a recreation center, community center, or boys’ or girls’ club; 4) a library or bookmobile. Neighborhood in poor condition: Based on responses of “yes” to any of the following three questions: “In your neighborhood, is there litter or garbage on the street or sidewalk? How about poorly kept or rundown housing? How about vandalism such as broken windows or graffiti?” Neighborhood with little social support: Based on responses of “definitely agree,” “somewhat agree,” “somewhat disagree,” or “definitely disagree” to the following four statements about their neighborhood or community: “People in this neighborhood help each other out; we watch out for each other’s children in this neighborhood; there are people I can count on in this neighborhood; if my child were outside playing and got hurt or scared, there are adults nearby who I trust to help my child.” Responses were scored 1–4 (“definitely agree” through “definitely disagree”), and an average score was calculated; averages ≥2.25 indicated a lack of support. Neighborhood unsafe: Based on responses of “never” or “sometimes” (compared with “usually” or “always”) to the question, “How often do you feel [the child] is safe in your community or neighborhood?” ^† Significant differences in the prevalence of certain community factors were found between children with and without MBDDs in certain urban and rural areas. Neighborhood with limited amenities: no areas; neighborhood in poor condition: urban, large rural, and small rural areas; neighborhood with little social support: urban, large rural, and isolated areas; neighborhood unsafe: no areas. ^§ Urban and rural designations were determined using the four-category classification of the 2006 RUCAs, a census tract–based classification system. Urban areas (RUCA codes 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1) include metropolitan areas and surrounding towns from which commuters flow to an urban area; large rural areas (RUCA codes 4.0, 4.2, 5.0, 5.2, 6.0, and 6.1) include large towns (micropolitan areas) with populations of 10,000–49,999 and their surrounding areas; small rural areas (RUCA codes 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.2) include small towns with populations of 2,500–9,999 and their surrounding areas; isolated areas (RUCA codes 10.0, 10.2, 10.3, 10.4, 10.5, and 10.6) are not near towns with a population of ≥2,500 (Source: US Department of Health and Human Services, Health Resources and Services Administration. The health and well-being of children in rural areas: a portrait of the nation 2011–2012. Rockville, MD: US Department of Health and Human Services; 2015. https://mchb.hrsa.gov/nsch/2011-12/rural-health/pdf/rh_2015_book.pdf).