W and Well-Being of Children in Rural Areas: A Portrait of the Nation DEC 1 179758 US. Department of Health and Human Services Health Resources and Services Administration SERVICE 093‘“ 5"qu Vb / S a E m ‘6? C 43> 1,, (”Page Health fell-Being of Children Health Resources and SeMces Administration, Maternal and Child Health Bureau. The National Survey of Children’s Health 2003. Rackville, Maryland: [1.3. Department L of Health and Human Services, 2005. Individual copies of this report are available at no cost from the HRSA Information Center, 20. Box 2910, Merrifield, VA 22116; I-888-ASK-HRSA; or ask@hrsa. gov. The publication is also available online at www.mchb.hrsa.gav and wwwcdc.gov/nchs/slaits.htm PuEL, The National Survey of Children's Health Table of Contents Introduction 4 1 ’1 \ \ The Child 7 The Child’s Family 39 Overall Child Health Status 8 Parenting Aggravation 40 Children with Moderate or Severe Smoking in the Household 41 Health Conditions 10 Breastfeeding 12 fl Children with Moderate or Severe @ Socio-Emotional Difficulties 14 _ Impact of 1 Socio-Emotional Difficulties 16 Overweight 18 Injury 20 Parents’ Concerns 21 Current Health Insurance 23 The Child and Coverage Consistency 25 Family’s Neighborhood Preventive Health Care Visits 27 Safety of the Child Preventive Dental Visits 29 in the Neighborhood 44 Medical Home 31 Child Care 46 Staying Home Alone 33 Repeating a Grade 35 Regular Physical Activity 37 Technical Appendix 47 Endnotes 48 The National Survey of Children’s Health w a >snvu:g\.,l N DEPARTMENT OF HEALTH 8: HUMAN SERVICES Health Resources and Services Administration Rockville MD 20857 Dear Colleagues: The Health Resources and Services Administration is pleased to present this chartbook highlighting the major findings of the National Survey of Children’s Health on the health of children in rural areas. This survey, the first of its kind, presents national- and state—level information on the health and well-being of children and their use of health services. The survey includes many positive findings about the health of both rural and urban children. The National Survey of Children’s Health found that children in urban and rural areas are equally likely to be healthy, with about 84 percent of children reported to be in excellent or very good health regardless of location. And rural children are more likely than their urban peers to get regular exercise and to be safe in their neighborhoods, according to their parents. However, children in rural areas face some specific health risks. Rural children are less likely to be breastfed for at least six months and are more likely to live in households where someone smokes than children in urban areas. In addition, specific subpopulations face particular risks; rural children in low—income families, for example, are more likely to have moderate or severe socio—emotional difficulties than children of the same income level in urban areas. We at HRSA hope that these findings provide useful information on children’s health and are helpful in your efforts to promote children’s health across the United States. Sincerely, The National Survey of Children’s Health Introduction Children in rural areas face particular risks to their health and well-being. Children who live outside of metro- politan areas are more likely to live in poor families,1 have higher mortality rates? and are more likely to use tobacco3 than their counterparts in urban areas. Rural families must travel greater distances to use health services; 452 non—metropolitan and frontier counties are designated as Health Professional Shortage Areas for primary care, and 1,409 entire counties are considered Medically Underserved Areas by the Federal Government.“ The National Survey of Children's Health (NSCH) presents a unique resource with which to analyze the health status, health care use, and risk factors experienced by children in rural areas in the context of their families and communities. The NSCH was designed to measure the health and well-being of children from birth to age 17 in the United States while taking into account the environment in which they grow and develop. Conducted for the first time in 2003, the survey collected information from parents about their children's health, including oral, physical and mental health, health care utilization and insurance status, and social well-being. Aspects of the child’s environment that were assessed in the survey include family structure, poverty level, parental health and habits, and community surroundings. The survey was supported and developed by the US. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) and was conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics (NCHS). How Locations were Defined Children were classified according to their residence in an ”urban focused” area, a large rural area, or a small or isolated rural area, based on the size of the city or town and the commuting pattern in the area. Urban-focused areas include metropolitan areas and surrounding towns from which commuters flow to an urban area; large rural areas include large towns (”micropolitan” areas) with popula- tions of 10,000 to 49,999 persons and their surrounding areas; and small or isolated rural areas include small towns with populations of 2,500 to 9,999 persons and their surrounding areas. The map on page 6 shows how these three types of areas are distrib- uted across the United States. Of the 72.7 million children in the U.S., 58.2 million live in urban—focused areas, 7.2 million live in large rural areas, and 7.3 million live in small rural or isolated areas. Findings of the Survey Children in rural areas are more likely to be poor than those in urban—focused areas: of children in small or isolated areas, 22.9 percent have family incomes below the Federal poverty level, as do 19.8 percent of those in large rural areas; this compares to 17.0 percent of children in urban- focused areas. Rural children are also more likely to be non-Hispanic White. Among children in urban areas, 57.2 percent are White, compared to 73.3 percent of children in large rural areas and 76.2 percent of children in small rural towns. The NSCH found that children’s health status does not vary substan- tially by location: approximately 84 percent of children are reported by their parents to be in excellent or u very good health, regardless of their urban or rural status. However, rural children do face specific health risks. Children in both large and small rural areas are significantly less likely to be breastfed for at least 6 months, as the American Academy of Pediatrics recommends: 40.5 percent of children in urban-focused areas are breastfed for 6 months or more, compared to 31.7 percent of children in large rural areas and 31.4 percent of children in small rural communities. In addition, rural children are more likely to live in households where someone smokes. More than one-third of children in rural areas (37.0 percent of children in large rural areas and 38.1 percent of children in small rural or isolated areas) live in households with a smoker, compared to 27.5 percent of urban children. Rural children may experience other risks to their well-being as well. School-aged children in large and small rural areas are more likely than urban children to have repeated a grade: 13.1 percent of children aged 6-17 in large rural areas and 13.3 percent of children in small or isolated rural areas have repeated a grade, compared to 10.8 percent of children in urban-focused areas. Rural children, especially those in small or isolated areas, are also more likely to stay home alone. Among 6— to 11-year-olds in small or isolated rural communities, 18.7 percent are reported to have spent any time caring for themselves, without the supervi- sion of an adult or older child in the past week, compared to 16.1 percent of children in large rural areas and 15.6 percent of children in urban- focused areas. In some cases, the effect of living in rural areas is particularly pronounced The National Survey of Children’s Health for specific subpopulations. For exam- ple, low-income children in rural areas are at higher risk of missing 11 or more days of school due to illness and to have moderate or severe social-emotional difficulties than children of the same income level in urban-focused areas or higher-income children in rural areas. Some risk factors are especially prevalent among specific racial/ ethnic groups: compared to their urban counterparts, American Indian/Alaska Native children in small rural areas are twice as likely to be overweight, non—Hispanic White children in rural areas are more likely to experience gaps in health insurance, and rural non-Hispanic Black children are less likely to be breastfed for at least 6 months. Living in rural areas also has health benefits for children. A higher percentage of children in rural com- munities are reported by their parents to be safe in their neighborhoods (90.2 percent of children in small or isolated and 86.9 percent of children in large rural areas are usually or always safe in their neighborhoods, compared to 82.6 percent of children in urban-focused areas). Rural children are also more likely to exercise regu- larly: 75.3 percent of children in small rural and 73.9 percent in large rural areas are reported to exercise regularly, compared to 70.4 percent of children in urban areas. This book presents information about the health and health care of children by location and by major demographic characteristics such as age, sex, race and ethnicity, and family income. Unless otherwise noted, all graphs provide information on children from birth to age 17. Children were classified by race and ethnicity in six categories: non-Hispanic White, non-Hispanic Black, Hispanic, non- Hispanic American Indian/Alaska Native (alone or in combination with other races), other single races, and other combined races. q The Technical Appendix of this chartbook presents important infor- mation about the survey sample and methodology. For more detailed analyses of the survey results, the Data Resource Center on Child and Adolescent Health (DRC) Web site provides online access to the survey data. The interactive data query feature allows users to create their own customized tables and to compare survey results at the national and State level, and by relevant subgroups such as age, race and ethnicity, and family income. Sponsored by HRSA’s MCHB, the Web site for the DRC is: www.mschdata.org More complex analyses of the data can be conducted using the public use data set available from the NCHS at: www.cdc.gov/nchs/about/major/slaits /nsch.htm or through the MCHB Web site at www.mchb.hrsa.gov/programs/ dataepi Rural-Urban Commuting Areas (RUCAs), 20055 zip Code Areas 8 I Urban Focused I Large Rural City/Town Focused Small Town and Isolated Rural Focus The National Survey of Childrenfs Health 7, w -;:5/'// The Child While all children need regular preventive care and care when they are sick, and all parents share concerns for their children’s health and safety, the health issues faced by children in rural areas may differ from those of urban children. This section presents information on children’s health status, their health care, and their activities in and outside of school. Taken together, these measures present a snapshot of children’s health and well-being that reflects a wide range of aspects of their lives. Children’s health status was measured through parents’ reports of their children’s overall health status as well as whether they had moderate or severe health or socio-emotional problems. In addition, parents were asked about their children’s injuries and their concerns about their children’s development and behavior. Children’s access to health care and parents’ satisfaction with the health care their children receive were measured through questions about children’s health insurance coverage and their use of preventive medical and dental services. Several survey questions were also combined to assess whether children had a ”medical home,” a source of primary care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.6 Children’s participation in activities in school and in the community represents another important aspect of their well-being. The survey addressed whether school-aged children had ever repeated a grade and whether they were ever left home alone. In addition, parents were asked about their children’s participation in physical activities on a regular basis. The National Survey of Children’s Health w Percent of Children in Excellent or Very Good Health, by Location 100 r 84.5 Overall Child Health Status A child's general health status (as perceived by his/ her parents) is a useful measure of his/her overall health and ability to function. Parents were asked to rate their child’s health status as excellent, very good, good, fair, or poor. Regardles of location, approximately 84.01;“ "' :E-ctdldren are reported by th in excellent or ve alth. 0f children living in? percent are reporte; or very good health; the Same is true of 84.2 percent of children in large rural areas and 84.5 percent of children in small rural areas. Percent of Children | I -_ * Total Urban Large Small Rural/ excellent Focus Rural Isolated The Child > Overall Child Health Status The National Survey of Children’s Health w Percent of Children in Excellent or Very Good Health, .2, by Location and Age Urban Focus ‘1 Large Rural 100 # Small Rural/Isolated cont’d l7 Overall, younger children are more likely than older children tobe in excellent or very good health. However, within eachlage group child health status does not vary considerably by area of residence. Among children from birth through age 5, 86.0 percent located in an urban area are reported to be in excellent or very good health, while the same, istrue of 85.9 percent of the youngest children living in large rural areas, and 851 percent Percent of Children in Excellent or Very Good Health, 0f the youngest children living in by Location and Race and Ethnicity small rural areas. A similar pattern Urban Focus Large Rural - 87.8 88.5 i— Small Rural/Isolated 90.0 Percent of Children 0—5 Years 6-11 Years 12-17 Years is seen among children 6-11 years of age, and 12-17 year . age. C " cl health status varies more not bly across residence within different racial and ethnic groups. Among White children, those living in urban areas are most often reported to be in excellent or verygood health (91.5 percent), while those living in large rural‘aréas are least likely to be in excellent or very good health (87.8 percent). As with White children, Black children are most likely to be reported by their parents to be 1 , , - ,, excellent or veryfgood health if they - I i I live in an urbafarea (79.7 percent), White Black Hispanic Multiracial Axilzrsiigndggiin/ Other ghowever those living in small rural "areas are least likely to be in excellent or very good health (72.3 percent). Among Hispanic children, those living in a large rural area _are;__most likely to be in excellent orvery good health percent are reported to be in excellent? ' status of American Indian/Alaska (69.8;percent); among Hispanics living or very good heait ' tapproximately Native children does not vary _ _ , _ in small or isolated areas, only 59.8 35. percent, the pa, ereported health considerably by area of residence; 83.9 85.2 343 85.1 74.0 Percent of Children The Child > Overall Child Health Status The National Survey of Children’s Health w asthma or‘emotional or h L problems, which may hav on the child. Overall, 7. 9 percent of children are reported by their parents residence. Children lrvmg in large , rural areas are most often reported rents to have such health :3 tditions (9,0 ’ at). The rate d of such heal _ children living 1 is reported to be 8.1 percent, _ the lowest rate, 7.7 percent, oc E _ among child: It living in urban areas. Percent of Children Percent of Children with Moderate or Severe Health Conditions, by Location 100 80 60 4O 20 Total Urban Large Small Rural/ Focus Rural Isolated The Child > Children with Moderate or Severe Health Conditions 10 The National Survey of Children’s Health w Percent of Children with Moderate or Severe Health Conditions, by Location and Sex 100 80’— Urban Focus Large Rural Small Rural/Isolated Overall, boys are more likely to have moderate or severe health conditions than girls, regardless of location. For both sexes, moderate or severe health conditions are most likely to he reported among children Percent of Children 20’- Male Female tions become less' cdmmon among children with increasing family income. With regard to area of residence, moderate or severe health conditions are generally more prevalent in _ 1 large and small mral areas, except 100 among children with family incomes [- ‘ “of 200-399 percent of the Federal '_ poverty level; among these children, _ so ‘ such health conditions are most commonly reported in urban locations. Urban Focus _ 60 _ Large Rural Small Rural/Isolated Percent of Children with Moderate or Severe Health Conditions, by Location and Family Income Percent of Children 40—— 20“ 13.2 13.3 Less than 100% FPL" 100-19979 FPL ZOO-399% FPL 400% or More FPL *Federal Poverty Level, equal to $18,400 for a family of four in 2003. The Child > Children with Moderate or Severe Health Conditions 11 The National Survey of Children’s Health w Percent of Children Breastfed 6 Months or More, by Location 100 F 80— Breastfeeding -‘ Breast milk is widely recognized ffto be the ideal form of nutrition to: infants. Breastfed infants are less susceptible to infectious diseases and are less likely to suffer from 40 diabetes, overweight and obesity, 3” 31-4 lymphoma, leukemia, and Hodgkin’ 5 disease, and asth" a c’ 7 40.5 Percent of Children 38.8 20_ 0 l I Total Urban Large Small Rural/ Focus Rural Isolated Academy of Péidiatrics recommends that, with few exceptions, all-infants be fed with breast milk exclusively irfor the first 6 months of life. ‘ Overall, 38. 8 percent of children rel-«breastfed for at least 6 months ‘ ' ugh they may not have been usively breastfed). Breastfeeding his duration is noticeably more Eco _ mon among children living 1n urban areas (40. 5 percent). While breastfeeding for at least 6 months is less common in rural areas, the rates are similar I) ' ‘ The Child > Breastfeeding 12 The National Survey of Children’s Health Overall, breastfeeding through at least 6 months becomes more common with increasing family income. The highest breastfeeding rates are among children living in urban areas with family incomes of 400 percent of the Federal poverty level (FPL) or above (47.9 percent); conversely, the lowest rates are amen" hfld ‘ living in large rural areas , , ' ricomes below 100 percent» " ipercent). Breastfee aries consider- ably by location, l «muracial and ethnic groups. With few exceptions, within each racial/ethnic group, breastfeeding is more common among children in urban areas. Rates for Hispanic children, however, are reported to be approximately the same (around 40 percent) across locations, and rates among American Indian/Alaska Native children are highest in small rural areas and lowest in large rural areas (42.0 and 25.5 percent, respectively). Overall, the highest reported breastfeeding rates occur among other races and White children nurban areas (44.8 and: *’ and America children livin ___ . mang Black children living in small rural areas (8.6 percent). Percent of Children Percent of Children Percent of Children Breastfed 6 Months or More, by Location and Family Income 100 — Urban Focus Large Rural 80 _ Small Rural/Isolated 60— Less than 100% FPL* 100.199% FPL ZOO—399% FPL 400% or More FPL 'Federal Poverty Level, equal to $18,400 for a family of four in 2003. Percent of Children Breastfed 6 Months or More, by Location and Race and Ethnicity 100 — Urban Focus Large Rural 80 __ — Small Rural/Isolated 404 40.0 414 43.0 41.1 42.0 40 20 White Black American Indian/ Other Alaska Native Hispanic MultiraCIal The Child > Health Status > Breastfeeding 13 The National Survey of Children’s Health W Percent of Children Aged 3-17 with Moderate or Severe Socio-Emotional Difficulties, by Location 100 80 , 1 Children with Moderate or Severe Soda-Emotional ’ Difficulties 60 percent of children are reported empamnts to have difficulty with ' neentration, or t. theirs; Percent of Children 40 anal 20 _ 9.5 I Total Urban Large Small Rural/ Focus Rural Isolated A y ,(5 ll, rural'areas. The Child > Children with Moderate or Severe Socio-Emotional Difficulties 14 The National Survey of Children's Health In general, moderate or severe socio-emotional difficulties are more common among boys, older children, and children with lower family incomes; however, there is little variation by location within these groups. For instance, 11.1 ‘ areas are repo in large rural areas and 12 .4 percent of boys 1n small rural areas. The rates among girls are lower and do not follow the same pattern: rates are highest among girls in large rural areas (8.4 percent) and lowest in small rural areas (6.4 percent). A similar lack of pattern is evident by age: rates among 3- to 5-year-olds are lowest in urban areas (4.8 percent) and highest in small rural areas (5.2 percent), but rates among 12- to 17-year-olds are lowest in urban areas (10. 8 percent) and highest in large rural areas (11. 7 percent). One of the most noticeable differences by location is among children living below poverty level: rates; re’n living in urban areas 1 percent, compared to a rate -of‘17.7 percent in large rural areas. Percent of Children Percent of Children Percent of Children 100 80 60 40 20 100 80 60 40 100 80 60 40 20 w Percent of Children Aged 3-17 with Moderate or Severe Socio-Emotional Difficulties, by Location and Sex Urban Focus _ Large Rural Small Rural/Isolated 11_1 12.3 12 4 _- . Male Female Percent of Children Aged 3-17 with Moderate or Severe Socio-Emotional Difficulties, by Location and Age Urban Focus _.. Large Rural Small Rural/Isolated 3-5 Years 6-11 Years 12-17 Years Percent of Children Aged 3-17 with Moderate or Severe Socio-Emotional Difficulties, by Location and Family Income Urban Focus _ Large Rural Small Rural/Isolated l _ 17.7 131 15.9 Less than 100% FPL“ 100-199% FPL ZOO-399% FPL 400% or More FPL 'Federal Poverty Level, equal to $18, 400 for a family of four in 2003. The Child > Children with Moderate or Severe Socio-Emotional Difficulties 15 The National Survey of Children's Health Impact of Socio- Emotional Difficulties Some children have difficulty with ' emotions, behavior, concentration, or ability to get along with others. Parents of children with socio- emotional difficulties were asked about the degree of "burden” their child’s condition puts on the family. a great deal, a me a little, or not 3 families of 28__pe with socio- emoti affected moderately Families of children 1n urban and small rural areas are approximately equally likely to be affected moder— ately or a great deal (27.9 and 28.8 percent, respectively). Percent of Children with Socio-Emotional Percent of Children Difficulties Whose Difficulties Impacted the Family Moderately or a Great Deal, by Location 100 _ 80— 60— 28.0 2719 28.0 28's 20 __ o | | Total Urban Large Small Rural/ Focus Rural Isolated The Child > Impact of Socio-Emotional Difficulties 16 The National Survey of Children’s Health In general, boys’ socio-emotional difficulties are more likely to impact their families moderately or a great deal than those of girls. Within each sex, there is slight variability across locations: among males, impact on the family is most likely to occur in small rural areas (31.0 percent) and least likel to are r in urban areas (28.1'p mong girls, impact is mos toCcur in urban areas (2 H cent) and least likely to occurinlarge rural areas (24.4 percent). As with sex, there is slight variabil- ity in the impact of soda-emotional issues on the family across location within different age groups. In general, impact is more common as age increases. Among the youngest chil- dren, impact on the family is most likely to occur in large rural areas (25.6 percent) and least likely to occur in urban areas (21.6 percent); the same is true among 6- to 11- year-olds. Among children ages 12-17, impact is most likely to occur in small rural areas (33.5 percent) and least likely to ccur “large rural areas (31.3: p, ' Percent of Children Percent of Children 100 80 60 40 100 80 60 40 W Percent of Children with Socio-Emotional Difficulties Whose Difficulties Impacted the Family Moderately or a Great Deal, by Location and Sex ———" Urban Focus Large Rural 1—1 Small Rural/Isolated Male 25.1 Percent of Children with Socio-Emotional Difficulties Whose Difficulties Impacted the Family Moderately or a Great Deal, 21i6 by Location and Age Urban Focus Large Rural _ Small Rural/Isolated 24.4 25-5 25-1 0-5 Years 6-11 Years 33.5 12-17 Years The Child > Impact of Socio-Emotional Difficulties 17 The National Survey of Children’s Health Overweight thy body weight is critically rtant to overall health and well- ,both during childhood and er in life. Risk factors for heart disease, such as high cholesterol and high blood pressure, occur more frequently among overwe1ght children Overweight rs- a to type-2 diabe of going on to bec0me‘0verweight or obese adults, this rate is even higher among children with overweight or ‘ ‘ 8- parents.8 Overweight and obesity eir associated health problems direct and indirect costs that ignificant economic impact ._ .health care expenditures. NSCH measures overweight _1-dren through parent- reported height and weight measures. ”Overweight” means that the child’s Body Mass IndexlBMI), calculated from the parent~ weight, is ate centile for se " is considered is meansthat a 7 children of the lower BMIs, ac _ representative data on height and weight that were measured by health refe ssiOnals' in other research studies. rail, based on parent-reported and weight, almost 15 percent Percent of Children Aged 10-17 Who Are Overweight, by Location 100 80 60 Percent of Children 40 20 _ 14.8 Total Urban Focus 17.1 17.4 I I: I Small Rural/ Isolated Large Rural of children aged 10—17 in the United States are considered overweight. Children in urban areas are somewhat an children living in ‘ overweight. 0f Kim,” 23‘ g children living in urban areas, 14.2 percent are overweight; these figures are 17.1 and 17. 4 percent, reSpecfively, for children m l‘* - small rural areas. ' The Child > Overweight 18 The National Survey of Children’s Health In general, boys, younger children, , and children with lower family incomes are more likely to be overweight than _ their counterparts. Within each of these demographic groups, children living in rural settings are more likely to be overweight than their urban counterparts. For instance, 17.2 percent ban area are differences by location oCCurs among children ages 12 14: 13. 3 percent of children in this age group who live in an urban area are overweight, while the same is true of 18.7 percent of children living in large and small , rural areas. In most income categories, children in urban areas are least likely , to be overweight. For example, 21.8 percent of children living in urban areas are considered overweight, compared to 26.3 percent in large rural areas. The only exception is among children with family incomes of 100- 199 percent of Federal poverty least likely to rweight 1n large rural areas (20 3 and 18.1 percent, respectively). Percent of Children Percent of Children Percent of Children Percent of Children Aged 10-17 Who Are Overweight, 100 — by Location and Sex 80- Urban Focus 60 _ Large Rural Small Rural/Isolated 4O — 21,1 21-7 17.2 . 20— Male Female Percent of Children Aged 10-17 Who Are Overweight, by Location and Age 100 — 80— Urban Focus 60 — Large Rural Small Rural/Isolated 4O — F 24.9 213 23.7 20 J. I 0 I 10-11 Years 15-17 Years 1244 Years Percent of Children Aged 10-17 Who are Overweight, 100 — by Location and Family Income 80— Urban Focus 60 _ Large Rural Small Rural/Isolated 40— 20 13.2 15'4 148 ZOO-399% FPL 1oo-199% FPL Less than 100% FPL" 400% or More FPL 'Federal Poverty Level, equal to $18,400 for a family of four in 2003, The Child > Overweight 19 The National Survey of Children's Health Injury ,[r‘Hnintentional injury—including ffl‘rnotor vehicle crashes, falls, and 'cutsmis a major risk to children’s health and is the leading cause of death for children over 1 year of age. For the NSCH, parents of children aged 5 and under were asked whether their child he ' L ' ‘ attention for over the past 9 percent of ch experience injury than children 1n urban areas (10.0 versus 9. 3 percent, respectively). The injury rate of hildren living in large rural areas percent) is similar to that of ran in urban areas. his slightly higher injury rate in rural areas is no longer evident the data are further divided _ her demographic variables. For instance, the past—year injury rate among children with family incomes below the Federal overty level (FPL) is highest 1n 2.0 family incomes fit of FPL, rates a» rural areas (1 _ in large rural areas (7,, _ The rates among children with hrgher family incomes are as varied as these among children with lower I lily incomes. Percent of Children The Child > Injury 20 100 80 60 40 20 Percent of Children Aged 0-5 Years with Injuries in the Past Year, by Location 100 — 60— 40— Percent of Children Small Rural/ Isolated Total Urban Focus Large Rural Percent of Children Aged 0-5 Years with Injuries in the Past Year, by Location and Family Income Urban Focus Large Rural Small Rural/Isolated 12.0 9_4 12’1 10,8 11-1 95 10,4 10.2 Less than 100% FPL' 100-199% FPL ZOO-399% FPL 400% or More FPL *Federal Poverty Level, equal to $18,400 for a family of four in 2003. The National Survey of Children’s Health w Percent of Children Aged 0-5 Years with Parent-Reported Concerns About Their Learning, Development, or Behavior, by Location 100 _ Parents’ Concerns ‘ 80 _ The NSCH asked parents of children aged 5 and under about specific concerns in the areas of Speech, language comprehension, manual dexterity, motor skills, behavior, getting along with others,the ability.” to do things forthemselvesfi and pre~sehool and school skills. Overall, the parents of almost 37 percent of children reported concerns in at least one of these areas; However, little variation by location is evident: 36.4 percent of children in urban “‘3' 252:: :15; SEQ? areas have parents who reported; concerns, compared to 38.2 percent Egyof children'in large rural areas, and ' _' "37.2 percent of children in small / rural areas. H Percent of Children The Child > Parents’ Concerns 21 The National Survey of Children’s Health 100 _ 80 — 60— Percenl of Children “(41.2 percerl» ~ were also least often Male 100 — 80— 444 43,7 42.5 Percent of Children 40 20 W Percent of Children Aged 0-5 Years with Parent-Reported Concerns About Their Learning, Development, or Behavior, by Location and Sex Urban Focus Large Rural F Small Rura|/Isolated 39.9 40.4 4142 Female Percent of Children Aged 0-5 Years with Parent-Reported Concerns About Their Learning, Development, or Behavior, by Location and Family Income Urban Focus Large Rural Small Rural/Isolated 60 ’— Less than 100% FPL' 1oo-199% FPL ZOO-399% FPL 400% or More FPL 'Federal Poverty Level. equal to $18,400 for a family of four in 2003. The Child > Parents’ Concerns 22 The National Survey of Children’s Health w Percent of Children with Current Health Insurance, by Location Current" alth Insurance The NSCH asked parents if their child currently had any kind " health' msurance, including HMOs or government tans such as Medicaid. (In this survey, health insurance did not include coverage through the Indian Health Service.) Overall, over 91 percent of child 1‘: have current heal h insurance cover age. This rate d’ at vary substan— Percent of Children l ’ | Total Urban Large Small Rural/ Focus Rural Isolated compared to 91.5 percent of children in large mral areas and 90.3 percent of children in small rural areas. 13‘} The Child > Current Health Insurance 23 The National Survey of Children’s Health w Percent of Children with Current Health Insurance, by Location and Family Income Urban Focus Large Rural Small Rural/Isolated 94.2 89-4 87B In general rates of coverage increase" The rates , Percent of Children the pattern is not consisten _ 3' - incomes For instance, children with familymcomes below the Federal insured 1n urban areas 4.4 percent). _ _, Conversely, children with family 1 ‘ ‘ 0111.33 of 400 percent of FPL and ‘ *Federal Poverty Level. equal to $18,400 fora family of fourin 2003. We are most likely to be insured Less than 100% FPL' ice-199% FPL ZOO-399% FPL 400% or More FPL Percent of Children with Current Health Insurance, rural areas (94. percent). by Location and Race and Ethn1c1ty With regard to race and ethn , 3:93: £3,215 White children, children of multipp; {Small Rue/Isolated races, and children of other races are 119f most likely be insured, followed 100—— 957 942 939 944 948 95.7 89.3 89.7 92.6 92.944 848 80 income, rates by location Vi ,. Within each rac , although there is no con- 60 Percent of Children 40 percent), however, rates ameng Black” p children are highest 1n small rural 20 White Black Hispanic Multiracial American Indian/ Other Alaska Native The Child > Current Health Insurance 24 The National Survey of Children’s Health w Coverage Consistency ‘ Although over 90 percent of children _ ‘- have health insurance, some experience «periods of time when they are not -' covered over the course of a year. Overall, 15.0 percent of children experienced a gap in their coverage at some point over the past year (including those who were uninsured at the time ‘ cent of CM in health at some little by Tlclren in _ - -~ - ,_ » onsi-stent insurance coverage, as do 14. 6 percent of children 1n large rural areas and 15.6 percent of children in small rural areas. The Child > Coverage Consistency Percent of Children Percent of Children Lacking Consistent Insurance Coverage in the Past Year, by Location 100 80 60— 40 20.— 15 0 14,9 14 6 15 6 o | I Total Urban Large Small Rural/ Focus Rural Isolated 25 The National Survey of Children’s Health w Percent of Children Lacking Consistent Insurance Coverage in the Past Year, by Location and Family Income 100 — 80 — Urban Focus Large Rural , Small Rural/Isolated gemral, gaps in health insure _; ‘ g 60 _ rage are more likely to occur g { ldren with lower family " g are and children who are Hispanic _ g riCan Indian/Alaska Native. E 40 — Less than 100% FPL“ 100—199% FPL ZOO-399% FPL 400% or More FPL 'Federal Poverty Level, equal to $18,400 for a family of four in 2003. Percent of Children Lacking Consistent Insurance Coverage in the Past Year, by Location and Race and Ethnicity ‘f ft in small rural areas and nt in urban areas. , 100 _ c children, who experience "j 80 —— Urban Focus Large Rural Small Rural/Isolated E, 60 — 2 LE 0 ‘6 E (D 8 g 40 ~ ethnic group whose highest inconsistent coverage occurs i areas (16.4 percent). While . Black Hispanic Multiracial American lndian/ Other Alaska Native The Child > Coverage Consistency 26 The National Survey of Children’s Health w Percent of Children with a Preventive Health Care Visit in the Past Year, by Location 100 77.8 73-3 80 .alth Care Visits The Bright Futures guidelines for health 60 F supervision of infants, childIe 40 Percent of Children 20— _l Total Urban Large Small Rural/ Focus Rural Isolated _ nce, review appropriate nutrition, and answer any parental questions. Overall, almost 78 percent of children received a preventive the I t1 ear. Receipt - visi :ceably less likely' 1n rural area . percent of children in small rural areas and 74.3 percent in large rural areas received a - reventive visit in the past year, comp _ 78.8 perce‘n 'f‘children in urb areas. The Child > Preventive Health Care Visits 27 The National Survey of Children’s Health w Percent of Children with 3 Preventive Health Care Visit in the Past Year, by Location and Age 100 — l— Urban Focus Large Rural Small Rural/Isolated 73,7 70.3 70.4 Children of all ages in rural areas are less likel to receive a preventive Percent of Children instance, among children from birth 89.1 percent in urban areas children aged 6- 11 ye ose rates _. are 73. 6 and 64. 9 percent, respectively. :5 e oldest children, aged 12-17 years, or experience the highest rates of 0-5 Years 6-11 Years 12-17 Years Percent of Children with a Preventive Health Care Visit in the Past Year, by Location and Race and Ethnicity approximately the Sarne (70. 3 a 70. 4 percent, respectively). In each location, Hispanic children Sma" Rura"'5°'a‘ed Urban Focus 100 _ Large Rural 80.0 819 80.2 73.4 Percent of Children children had a prev _, visit in the past year, compared to 3.6 percent of White children and 76.3 percent '" Black children. White Black Hispanic Multiracial American Indian/ Other Alaska Native The Child > Preventive Health Care Visits 28 The National Survey of Children’s Health w Percent of Children with 3 Preventive Dental Visit in the Past Year, by Location 70.7 The Bright Futures oral health guidelines recommend that children Percent of Children {traditional recommendation for the periodicity of visits is 6 months“ thereafter, most professionals beli ' recommended, ’ propriate. 0 , I | dren received one dental visit Total £232 ELIE; 3163:3558” “the past year. A dental visit in the past year is slightly more common ‘ “Manama“... “w. The Child > Preventive Dental Visits 29 The National Survey of Children's Health 100 "‘ In general, children aged 6-11 ‘ ren with higher family é st 11ker to have % eventive den l t in E the past year. Within eac oup, &’ children in urban areas ar ,- , likely to receive a preventive dental visit; however, whether this' 18 least instance, the rate a " aged 1-5 years old is _ percent) in urban areas and lowest 0 ' percent) in large rural areas; (84.4 percent . rural areas (79 Children with family income : below the Federal poverty level (EFL) ‘00 tland childrenwith family incomes nt of FPL are most preventive dental likely in large rural areas (5; . 64 cent, respectively). The 60— Percent of Children incomes of 400 per 40 _ above occur in large " 1 and 84.5 percent, respectively).f7 20— 0-5 Years Less than 100% FPL' W Percent of Children with a Preventive Dental Visit in the Past Year, by Location and Age Urban Focus Large Rural Small Rural/Isolated 84.4 6-11 Years 12-17 Years Percent of Children with a Preventive Dental Visit in the Past Year, by Location and Family Income Urban Focus Large Rural Small Rural/Isolated 77.0 77.1 65.7 100-199% FPL ZOO-399% FPL 400% or More FF’L *Federal Poverty Level, equal to $18,400 for a family of four in 2003. The Child > Preventive Dental Visits 30 The National Survey of Children’s Health w Percent of Children with a Medical Home, by Location 100 T 80— Medical Home A number of the characteristics of high-quality health care for children , can be combined into the concept of the medical home. As defined by the American Academy of Pediatrics, children’s medical care should be accessible, family-centered, continuous, comprehensive i coordinated, compas- 60— 46.1 46.4 44.7 45.2 Percent of Children sionate,an an ve.6 The NSCH; nestions that sough ther a child’s heal standard - 0 Whether least Total Urban Large Small Rural/ Focus Rural lsolated one persona oc urse who knows him or her well; 0 Whether this personal doctor or nurse usually or always spends enough time with the family, explains things so the parent can understand, and provides U: , interpreter services when needed; _ it ‘ Whether this personal doctor or ‘ nurse usually or always provides L telephone advice or urgent care when the child needs it; 0 Whether the child has little or no problem gaining access to “Overall, 46.1 percent of children ive- care that meets this standar dren living in urban areas are htly more likely to have a medic least one preventive vi year, had little or no p access to specialty or having a personal doct special sendces-or'eq merit; and who usually or always 313 {me than children in other locations __ 0 Whether the child had apreven- time and communicated :c yearly W1 , , e urban rate is 46. 4 percent, com- L tive visit in the past year. families, provided telephone advice ' pared to 44,; percent in large rural , or urgent care when needed, and and 45. 2 :p ce lareas. A child was defined as having a medical home if he or she had at _ifo “ with the family after the ty care visits. The Child > Medical Home 31 The National Survey of Children’s Health In general, younger children and children with higher family incomes are most likely to have a medical home. Within each age group, the percent of children with a medical home varies little across location. For instance, 56.0 percent of children age 5 and younger in urban areas have a medical home 7 com ared to Teas. ars, the rates of medical hd _ "than, large rural, and small rural areas are 43.2, 40.2, and 40.8 percent, respectively. Slightly more variation is evident across locations by family income. The greatest difference is seen among , children with family incomes below f- the Federal poverty level (FPL): {among this group, the rate of medical Lhomes in urban areas is 29.0 percent compared to 38.4 percent in small rural areas. Among children with family incomes of 400 percent of FPL and above, the highest rate of medical homes occurs in urban areas (58.3 percent) while the lowest rate occurs in large rural areas¥(53 pe’rcent). Percent of Children Percent of Children Percent of Children with a Medical Home, by Location and Age Urban Focus l— Large Rural l f Small Rural/Isolated 100 — 80— 50— 56.0 552 56.3 40l— 20— 0-5 Years 6-11 Years 12-17 Years w Percent of Children with a Medical Home, by Location and Family Income Urban Focus 100 — Large Rural Small Rural/Isolated 80— 58.3 53.8 60— 50.9 5043 49.7 43.1 43.2 40 20 Less than 100% FF’L" 100-1 99% FPL ZOO-399% FPL *Federal Poverty Level, equal to $18,400 for a family of four in 2003. 400% or More FPL 55.4 The Child > Medical Home 32 The National Survey of Children's Health w Percent of Children Aged 6-11 Years Staying Home Alone, by Location 80— ,3" ying Home‘Alone Parents of 6— to 11-year-olds were asked if their children had spent any time caring for themselves- ‘ out the supervi ' n of an adult , child, for H small amount Of time, in th week. Overall, 60— Percent of Children 16 percent of children were reported to have been home alone for some 18.7 16,0 15.6 1611 , 20_ amount of time. Children in rural, :_;;‘:_7 areas, particularl small rural areas; than their urban; unterparts. Being I l me alone in the last week occurred Total Urban Large Small Rural/ Focus Rural Isolated fo‘ng 18.7 percent of children in small rural areas, compared to 16.1 percent in large rural areas and 15.6 L percent in urban are The Child > Staying Home Alone 33 The National Survey of Children’s Health In general, boys are more likely than girls to stay home alone, and Percent of Children the past week occurred among 16.9 percent living in urban areas, 17.8 percent living in large rural areas, and 1 ’0 percent in small rural areas. Staying] home alone occurred among girls at a rate of 14. percent, respectively; _ The pattern of higher rates of staying home alone in small rural as is not as strong with regard to :T’ly income. 17 instance, children (14.0 percent), but are about equa y A as likely to stay home alone in large ' rural andsmall rural areas (17.0 and of FPL and above are equal 3; likely to stay home alone in urban and small rural areas (18. 7 and 18. 6 percent, res. yly) and most likely to sta‘ e alone in large rural areas Percent of Children fl 100 80 100 80 60 4O 20 W Percent of Children Aged 6-11 Years Staying Home Alone, by Location and Sex Urban Focus Large Rural Small Rural/Isolated Percent of Children Aged 6-11 Years Staying Home Alone, by Location and Family Income Urban Focus Large Rural Small Rural/Isolated 20.1 18.7 19.5 17.0 16.9 18.3 160 16.2 18'6 13.6 13.5 400% or More FPL Less than 100% FPL" 100-199% FPL ZOO-399% FPL “Federal Poverty Level, equal to $18,400 for a family of {our in 2003. The Child > Staying Home Alone 34 The National Survey of Children’s Health W Percent of Children Aged 6-17 Years .2, Who Have Repeated a Grade, by Location 100 80 lRepeating a Grade Parents of school-aged children (6 years and older) were asked if their children had repeated one or more grades since starting school. Overall, 11.3 percent of children have repeated a grade. Children in rural areas are slightly more likely than children in urban areas to repeat a grade. 0f children in urban areas, 10.8 percent have repeated a grade, compared to 13.1‘percent in large rural and 13.3 percent in small l rural areas. Total Urban Large Small Rural/ L ' Focus Rural Isolated Percent of Children 40 133 The Child > Repeating a Grade 35 The National Survey of Children’s Health In general, boys, older children and children from families with lower small rural areas (16. 4 percent) The differen 3 across locations among al areas. ears, the (8 2 percent) and the highest rate 1115 in small rural areas (11.4 per- The rates among older children " ‘ em, although, hast rates occur I as with girls, in large rural as Children with lower family in are more likely to repeat a grade ,gjrural areas while children with higher ”"family' 111cc so in urba with fami poverty level, 27.2 percen rural areas repeated a gra , are more likely to do ‘ Among children percent in small rur Percent of Children Percent of Children Percent of Children 100 80 60 40 100 80 60 4O 20 100 80 60 4o— 20 W Percent of Children Aged 6-17 Years Who Have Repeated a Grade, by Location and Sex Urban Focus Large Rural Small Rural/Isolated Male Female Percent of Children Aged 6-17 Years Who Have Repeated a Grade, by Location and Age y—W Urban Focus Large Rural Small Rural/Isolated — 15.5 15.0 11.4 13-3 6-11 Years 12-17 Years Percent of Children Aged 6-17 Years Who Have Repeated a Grade, by Location and Family Income Urban Focus Large Rural Small Rural/Isolated 15.1 15.7 400% or More FPL Less than 100% FPL' 100~199% FPL ZOO-399% FPL *Federal Poverty Level, equal to $18,400 for a family of four in 2003. The Child > Repeating a Grade 36 The National Survey of Children's Health W Percent of Children Aged 10-17 Who Participate in Physical Activity on 3 or More Days per Week, by Location 100 Regular Physical Activity Physical activity plays a key role in health by helping children tomaintain an appropriate energy bala hich in turn he ' ‘ Physical - for certain ers, diabetes, and high blood pressure, and contributes to healthy bones and muscles.12 According to parent reports, 71.3 percent of childr aged 10-17 exercise on three more days per * week. Children in 2 ral areas are | I e likely than children in urban Total 232:: gag: STgiaZEBV as to participate in regular physical activity. Among children in urban H areas, 70.4 percent e e regularly, Percent of Children The Child > Regular Physical Activity 37 The National Survey of Children’s Health Boys, younger children, and children with; higher family incomes are most 111: y to exercise. Regular physical activity is more common among children in rural areasithan urban areas across all sex, age, and family income groups. Among boys, rates of physical activity in urban, largeéyrétiral, and small rural areas are 763,777.46, and 79.6 percent, respec- tively; rates among grrlsin these areas of residence are 64.3, 70.3, and 70.5 percent. Patterns are similar , for all three age groups, with children Ed 10-11 years living in small rural areas being__-especially likely to exercise on 3 . _ mere days per week (82.4 percent). _ Children from all family income“ levels are more likely to exercise in' _ rural areas, but one of the largest disparities between urban and rural areas occursiamong children with family incomes below the Federal poverty level (PPL): rates among- those children are 62.1 percent in urban areas, compared to 74.5 percent in largeeirural areas and 75.1 percent ural areas. Children with family incomes of 400 percent of PPL and above and living ' :large rural and small rural areas are particularly likely to exercise (78.4 and 78.8 4 cent, respectively). Percent of Children Percent of Children Percent of Children 100 80 60 40 20 100 100 80 60 4O 20 W Percent of Children Aged 10-17 Who Participate in Physical Activity on 3 or More Days per Week, by Location and Sex _ ‘—_1— Urban Focus Large Rural 7— Small Rural/Isolated 79.6 Male Female Percent of Children Aged 10-17 Who Participate in Physical Activity on 3 or More Days per Week, by Location and Age Urban Focus \ Large Rural l 4— Small Rural/Isolated 82.4 73.1 10-11 Years 12-14 Years 15-17 Years Percent of Children Aged 10-17 Who Participate in Physical Activity on 3 or More Days per Week, by Location and Family Income _ 1,, — Urban Focus Large Rural Small Rural/Isolated — 74.5 75.1 731 731 763 74,5 Less than 100% FPL' 1oo-199% FPL ZOO-399% FPL 400% or More FPL ‘Federal Poverty Level, equal (a $18,400 for a family of four in 2003. The Child > Regular Physical Activity 38 The National Survey of Children's Health w The Child’s Family The environment of the family provides the backdrop and context for children’s health and development. Two indicators of the family environment showed particular differences between rural and urban children: the percentage of children whose parents reported being aggravated by their children, and the percentage of children who live with people who smoke. 39 The National Survey of Children’s Health Parenting Aggravation The demands of parenting can cause considerable aggravation for families. Parents were asked how often during the past month they had felt that their child was much harder to care for than others of his or her age; how often the child did things that really bothered them; andhow often they had felt angry with th childuflverall, parents of 8 perce- answered ”usually. least one of these -_ ing aggravation Paren aggravation is noticeably lower among the parents of children living in small rural areas: parents of 6.7 percent of these chil- dren report aggravation, compared ptoyparents of 8.2 percent of children akin: urban areas. In general, the parents of older dren and children with lower ,zmily incomes experience more _ enting aggravation. In every age group, rates of parenting aggravation are lowest in rural areas. For instance, among children up to age 5, the par- ents of 6. 9 percent usually or always experience parenting aggraVation in urban areas, comp - 5. 7 and 5.5 pen: and small rural at This pattern holds children, with the h parenting aggravation among the parents of children aged 12- 17 years living in urban areas (10.0 percent). Rates of parental aggravation are _ lso lowest in mral areas across each *‘ome group. Children with family Percent of Children Percent of Children incomes below the Federal poverty level (FPL) living in urban areas are the, most likelyto have aggravated Percent of Children Whose Parents Are Usually or Always Aggravated, by Location Percent of Children Small Rural/ Isolated Total Urban Large Focus Rural Percent of Children Whose Parents Are Usually or Always Aggravated, by Location and Age 100 80 Urban Focus 60 Large Rural Small Rural/Isolated 0-5 Years 6-11 Years 12-17 Years Percent of Children Whose Parents Are Usually or Always Aggravated, by Location and Family Income 100 80 Urban Focus 60 Large Rural Small Rural/Isolated Less than 100% FPL' 100-199% FPL ZOO-399% FPL 400% or More FPL 'Federal Poverty Level, equal to $18,400 for a family of four in 2003. of FPL and above living in large rural and small mral areas are the least likely (3.4 3 df3 ‘ ' ‘ respectively). ' l ‘ rcent), while children i s of 400 percent The Child’s Family > Parenting Aggravation 40 The National Survey of Children’s Health W {00 Percent of Children Living \i/kk in Households with a Smoker, by Location 100 80 ,, Smoking ”in the Household . 60 Exposure to env1ronmental smoke— from cigarettes, cigars, or pipes,» can be a serious health hazard for children. Ac ording to the Centers for Disease _ "ntrol and Prevention, Percent of Children — 37.0 38'1 40 exposure to secondhand smoke is associated with higher rates of sudden infant death syndrome ( . | l Efffiarold used cigarettes, cigars, or pipe Tma' Urban Large Sma" Rum” -, , Focus Rural Isolated tobacco. Overall, almost one-thud of children live in households where someone smokes. Exp consi erably more com :1 in rural ofchildren in urban areas, 27.5 percent live with a smoker, compared to 37.0 percent of children in large rural areas and 38.1 percent of children in small rural areas; The Child’s Family > Smoking in the Household 41 The National Survey of Children’s Health w In general, older children, children iwith lowe f : ly incomes, and White dren with fanu Federal poverty ,, a smoker 1s least common in s Percent of Children Percent of Children Percent of Children rural areas »5 common in l_ ral areas percent). With'regard to race” ‘ nicity, American Indian/Alask Nature His children ' Percent of Children Living in Households with a Smoker, by Location and Age 100 Urban Focus 80 Large Rural Small Rural/Isolated 39,8 0—5 Years 6-11 Years 12-17 Years Percent of Children Living in Households with a Smoker, by Location and Family Income 100 Urban Focus 80 Large Rural Small Rural/lsolated Less than 100% FF’L‘ 100-199% FPL ZOO-399% FPL 400% or More FPL “Federal Poverty Level, equal to $18. 400 for a family of four in 2003. Percent of Children Living in Households with a Smoker, by Location, Race, and Ethnicity 100 Urban Focus Large Rural T Small Rural/Isolated 39.1 39.9 80 60 40 20 White Black Hispanic Multiracial American Indian/ Other Alaska Native ant) and most likely to live with a smoker percent) while urban children lassi- fied 1n the other races category and "ildren are least likely .6 percent. respectively). all rural areas are most (13.2 The Child’s Family > Smoking in the Household 42 The National Survey of Children’s Health w The Child and Family’s Neighborhood Urban and rural communities may differ in their support for families and children. Two indicators of a neighborhood’s family- friendliness—a child’s safety in the neighborhood and the availability of child care—can affect a family's comfort level (or can affect a family’s perception of their community and its support of children). These indicators showed particular differences by location. 43 The National Survey of Children’s Health w Percent of Children Who Are Reported to be Usually or Always Safe in Their Neighborhood, by Location 100 80 Families are more likely to feel . j, _ so comfortable in their neighborhoj they feel that ‘ Percent of Children 40 er, sometimes, usually, or always. Overall, parents of almost 84 percent _;_: of children report the 20 , o _l rural areas are more likely Total LFJman harge' STal: Tugal/ OCUS ura SO a e __ t their child IS safe than parentsof children in urban areas: 82.6 percent of children in are safe, according to thei compared to 86 9 percent The Child and Family's Neighborhood > Safety of the Child in the Neighborhood 44 The National Survey of Children’s Health 1%? cont’d _, Parents of children with higher family incomes and White, multiracial, and American Indian/Alaska Native children are most likely to report that their child is safe in his or her neigh- borhood. Within every income group, the percent of children whose parents report them to be safe in their neigh- borhood is highest in rural areas, although the disparity between urban and rural begins to diminish as income rises. For instance, among children with family incomes below the Federal poverty level (FPL), 66.5 percent in urban areas are reportedly safe in their neighborhood, compared to 82.7 percent in small rural areas; among children with family incomes of 400 percent of FPL and above, the rate in urban areas is 93.1 percent compared to 95.7 percent and 95.5 percent in large and small mral areas, respectively. In each racial and ethnic group, rural children are more likely to be reported as safe in their neighbor- hoods, with one exception: White children are least likely to be reported to be safe in the neighborhood in large rural areas (90.8 percent), although they are most likely to be considered safe in the neighborhood in small rural areas (93.4 percent). In all locations, White children are more likely to be reported to be safe in their neighborhood than are Black children: of urban White children, for example, 91.5 percent are reported to be safe, compared to 68.0 percent of‘urban Black children. Percent of Children Percent of Children W Percent of Children Who Are Reported to be Usually or Always Safe in Their Neighborhood, by Location and Family Income Urban Focus Large Rural i——- Small Rural/Isolated 88.9 r— 84.1 74.4 95.7 95.5 945 93.1 _ 92.1 Less than 100% FPL“ 100-199% FPL ZOO-399% FPL 400% or More FPL ’Federal Poverty Level, equal to $18,400 for a family of four in 2003. Percent of Children Who Are Reported to be Usually or Always Safe in Their Neighborhood, by Location, Race, and Ethnicity Urban Focus Large Rural f Small Rural/Isolated 83.8 88 6 90.7 86.4 34-2 82.9 83.1 81,0 While Black Hispanic American Indian/ Other Alaska Native Multiracial The Child and Family’s Neighborhood > Safety of the Child in the Neighborhood 45 The National Survey of Children’s Health w A Percent of Children Aged 0-5 Years m-I Whose Families Experienced Child Care Problems, by Location 100 — 80— Child Care 60 — bility of child care, and r, tov‘make backup child care, ants-in emergencies, is , _ important aspect of families’ 2° — mm __m their communities. Parents children from birth to age 5 were 0 _ asked about two common child care Total $33: :13; Srlnfcl'lalfgfl/ problems: how many times in the past month they had to make different child care arrangements due to cir- Percent of Children Aged 0-5 Years Whose Families Experienced cumstances beyond their control, and Child Care Problems, by Location, Race, and Ethnicity Percent of Children whether anyone in the family had to quit a job, not take a job, or greatly 10° change their job because of child 53 reproblems within the past year. 80 _ ovarian: parents of approximately of children reported that me or both of these types ‘ e issues. Problems with ' i:slightly more likely raliareas (35.2 percent) ,ezrural and urban areas , 3.0- percent, respectively). arents of children in almost acial and ethnic category more Urban Focus Large Rural [ Small Rural/Isolated ! l l 3 2 39.6 i — 33.7 5- 35.1 33's 31.7 31.4 60— 40 Percent of Children __ manly reported child care prob- White Hlspar‘llc MultiraCIal Amzrslignrg‘ciign/ Other ,lems inrrural areas than urban areas. However, problems with child care among Black children were most common in urban areas: the parents such issues. The parents of Hispanic of 39.6 percent of Black children in children were least likely to report urban areas had problems with child problems with child care, with rates care, compared to 35.1 percent in ranging from 24.2 percent in large , large rural and 31.7 percent in small rural areas to 31.4 percent in small 7 'mral- areas. The parents of American rural areas. {Alaska Native children were ‘5 l/ ethnic group most likely child care problems, with ‘ small rural areas reporting The Child and Family’s Neighborhood > Child Care 46 The National Survey of Children’s Health Technical Appendix w About the Survey The National Survey of Children’s Health (NSCH) was fielded using the State and Local Area Integrated Telephone Survey (SLAITS) mechanism. SLAITS is conducted by the US Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS). It uses the same large-scale random- digit-dial sampling frame as the CDC’s National Immunization Survey.“ Approximately 1.9 million telephone numbers were randomly generated for inclusion in the NSCH. After eliminating numbers that were determined to be nonresidential or nonworking, the remaining numbers were called to identify households with children less than 18 years of age. From each household with children, one was randomly selected to be the focus of the interview. The respondent was the parent or guardian in the household who was most knowledgeable about the health and health care of the children under 18 years of age. For 79 percent of the children, the respondent was the mother. Respondents for the remaining children were fathers (17 percent), grandparents (3 percent), or other relatives or guardians (1 percent). Surveys were conducted in English and Spanish. Overall, 5.9 percent of the interviews were completed in Spanish. Data Collection Data collection began on January 29, 2003 and ended on July 1, 2004, with interviews conducted from telephone centers in Chicago, Illinois; Las Vegas, Nevada; and Amherst, Massachusetts. A computer-assisted telephone inter- viewing system was used to collect the data. A total of 102,353 interviews were completed for the NSCH, with 87 percent of the interviews completed in 2003. The number of completed interviews varied by State, ranging from 1,848 in New Mexico to 2,241 in Louisiana and Ohio, with one exception: Only 1,483 interviews were completed in Utah. The cooperation rate, which is the proportion of interviews completed after a household was determined to include a child under age 18, was 68.8 percent. The national weighted response rate, which includes the cooperation rate as well as the resolution rate (the propor- tion of telephone numbers identified as residential or nonresidential) and the screening completion rate (the propor— tion of households successfully screened for children), was 55.3 percent. Several efforts were made to increase response rates, including sending letters to households in advance to introduce the survey, leaving toll-free numbers on potential respondents’ answering machines to allow them to call back, and providing small monetary incentives for those households with children who initially declined to participate. Data Analysis For producing the population-based estimates in this report, the data records for each interview were assigned a sampling weight. These weights are based on the probability of selection of each household telephone number within each State, with adjustments that compensate for households that have multiple telephone numbers, for households without telephones, and for nonresponse. With data from the US Bureau of the Census, the weights were also adjusted by age, sex, race, ethnicity, household size, and educational attain- ment of the most educated household member to provide a dataset that was more representative of each State's pop- ulation of noninstitutionalized children less than 18 years of age. Analyses were conducted using statistical software that accounts for the weights and the complex survey design. Responses of ”don’t know” and ”refuse to answer" were counted as missing data. Children’s areas of residence were classified according to the Rural—Urban Commuting Areas (RUCAs) developed by the Federal Office of Rural Health Policy.5 The 10 RUCA codes were grouped into three categories. ”Urban- focused areas” (RUCA codes 1.0, 1.1, 2.0, 2.1, 2.2, 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, 5.0, and 6.0) include large towns (”micropolitan” areas) with populations of 10,000 to 49,999 and their surrounding areas; and small or isolated rural areas (all remaining codes) include small towns with populations of 2,500 to 9,999 and their surrounding areas. Children were classified by race and ethnicity in six categories: non—Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic American Indian/Alaska Native (alone or in combination with other races), other single races, and other combined races. Racial and ethnic groups are mutually exclusive; that is, data reported for White, Black, multi- racial, and children of other races do not include Hispanics, who may be 47 The National Survey of Children’s Health Data Analysis, (’70nl1rmcd w of any race. These categories differ from the racial aggregation method recom- mended by the Office of Management and Budget, which keeps intact the five single-race categories and includes the four double—race combinations that are most frequently reported. This analysis did not employ these nine groups because sample sizes did not support it. However, a separate category was included for American Indian/ Alaska Natives, as well as those who are of other races, because their well-known health risks may vary by locality. Accuracy of the Results The data from the NSCH are subject to the usual variability associated with sample surveys. Small differences between survey estimates may be due to random survey error and not to true differences among children or across States. The precision of the survey estimates is based on the sample size and the measure of interest. Estimates at the national level will be more precise than estimates at the urban/ rural level, and those for all children will be more precise than estimates for subgroups of children (for example, children 0-5 years of age or children within the same race). For national estimates of the health and health care for all children, the maximum margin of error is 0.6 percent. For esti- mates reported by area of residence for all children, the maximum margin of error is 1.6 percent. Availability of the Data All data collected in the NSCH are available to the public on the NCHS (www.cdc.gov/nchs) and MCHB (www.mchb.hrsa.gov) Web sites, except for data suppressed to protect the confidentiality of the survey subjects. Data documentation and additional details on the methodology15 are available from the NCHS: www.cdc.gov/nchs/slaits.htm Interactive data queries are possible through the Data Resource Center on Child and Adolescent Health (DRC) for the NSCH: www.mschdatacrg The DRC provides immediate access to the survey data, as well as resources and assistance for interpreting and reporting findings. Data Limitations The findings presented here are based entirely on parental reports; however, the majority of questions have been 1 United States Department of Agricul Research Sen/ice. Rural Children at a Glance. Economic Information Bulletin Number 1, March 2005. CdtMS, Ingram DD, Makuc DM, etal. Urban {Health Chartbook. Health, United States, 2001. Hyattsville, Maryland ‘ nal Center for Health Statistics. 2001. 3 Johnston LD, O’Malley PM, Backman JG, Schulenberg JE. Monitoring the Future: National Survey Results j, on Drug Use, 1975-2004: Volume I, Secondary School Students. NIH Publication No. 05-5727. Bethesda, Maryland: National Institute on Drug Abuse, 2005. ices Administration, http. //datawarehaus_e _rsa. gov 5 USDA Economic Research Service and the WW: Rural Health Research Center. What are Rural‘eUrban Commuting Areas? http://fammed.washington.edu/ wwamirhrc/rucas/rucas.html tested for validity when reported by parents. In some cases, data are missing for some respondents for some ques- tions. In addition, certain populations of children, such as those with no 6 American Academy of Pediatrics. , , Initiatives for Children with Special Needs Project Ad isary Committee. The medical home. Pediatrics - ‘110(1):184-86. rBreastfeeding. Breas of human milk. Pedi call to action to prevent and decrease overwezg and obesity. Washington, DC: US. Department;_ Health and Human Sen/ices; 2001. Centers for Disease antral and Prevention, and Health Physical Actiwly Mfor children an Available from: http. //www. cdc. gov/n bmi/bmi for-agehtm. Updated 8 June, . 10 Green M, Palfrey JS, eds. 2002 Bright Futu s: guideline for health supervision of infants, children, L I (2nd rev. ed). Arlington, KIL- National ‘ ' Child Health. telephones at home or those living in an institutional setting, are excluded from the survey. massimo P, Holt K. Bright Futures in practice. " Prevention, National , ntion and Health of a vaccination surveillance sy, Reports 115. 65 77. 2000. , th Stat N43); ‘ 48 EEEEEEEEEEEEEEEEE DDDDDDDDDD Maternal and Child Health Bureau 5600 Fishers Lane, Room 18-05 Rockville, MD 20857 301-443-2170 www.mchb.hrsa.gov SERVICES. 0W Qty ‘6 5?? US.DepurMofHed1hdeumnServices % O Hodfll Rum: and Suvim mm (”“130