Voice and trust as predictors of parental satisfaction with child health care among a head start sample.
Abstract: The specific aim of this study is to identify factors related to parental satisfaction with a child health provider's services among a sample of Head Start parents. This is a retrospective study with a sample of 250 consentedparents/guardians of registered Head Start children (3-5 years old), in South Los Angeles, California, USA. The study results showed that parents who were empowered or having a voice to demonstrate concerns about their child's health to the provider, negotiate a health care management plan, and ask questions, were nearly six times more likely to have reported receiving caring services from their child's providers (OR = 5.78; CI = 2.882-11.8, P [less than or equal to] .05). Also, parents who reported trusting their child's provider were eight times more likely to report receiving caring services from their child's providers (OR = 8.63; CI = 9.30-18.1, P [less than or equal to] .05). These results have implications for health provider training in patient-centered care and for patient empowerment during a medical encounter.
Subject: Parenting (Research)
Children (Health aspects)
Children (Research)
Health care industry (Research)
Patient satisfaction (Research)
Authors: Besong Tataw, David
Bazargan-Hejazi, Shahrzad
Patel, Priya
Pub Date: 06/22/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Summer, 2010 Source Volume: 25 Source Issue: 3
Topic: Event Code: 310 Science & research Computer Subject: Health care industry
Product: SIC Code: 8000 HEALTH SERVICES
Accession Number: 308741510

Conceptualizations of access in the past decade have expanded the 1993 institute of medicine's definition of access, "the timely use of personal health services to achieve the best possible health outcomes," to encompass individual and community entrance into the system, navigation in the system and satisfaction with the system (Gold & Stevens, 1998; Lurie, 1997). Because children depend on caregivers to access health services, we can only understand the quality of their care through their parents or guardians. This study seeks to understand the factors which contribute to the quality of health services for children in Head Start programs. This aim is achieved by looking at factors associated with parental satisfaction with a child's health services.

Parents' satisfaction with the health care their children receive is an important quality measure for both health services administrators and researchers because satisfaction has been linked to health status and clinical process outcomes including compliance to medical treatment, prevention interventions, and improvements in health conditions (Cameron, 1996; all et al., 1998; Deyo & Diel, 1986; Winefield, Murrell & Clifford, 1995; Redekop et al., 2002; Alazri & Neal, 2003).

The Client-provider fit is a critical factor in defining access and determining the quality of a patient's experience in the provider environment. Penchansky & Thomas (1981), grouped access characteristics into five A's of access to care: affordability, availability, accessibility, accommodation, and acceptability. Affordability is determined by how the provider's charges relate to the client's ability and willingness to pay for services. Availability measures the extent to which the provider has the requisite resources, such as personnel and technology, to meet the needs of the client. Accessibility refers to geographic accessibility, which is determined by how easily the client can physically reach the provider's location. Accommodation reflects the extent to which the provider's operation is organized in ways that meet the constraints and preferences of the client. And finally, acceptability captures the extent to which the client is comfortable with the more immutable characteristics of the provider, and vice-versa. A provider's accommodation of patients' preferences, a patient's individual characteristics, and a patient's acceptability of the provider's services create the structural and psychosocial properties which shape a patient's satisfaction with care.

The strength of the patient-provider relationship is the building block on determining whether patients are satisfied with the health care they receive from their provider. Many studies have been done to try to determine what factors, both in patients and providers, lead to better satisfaction with the health care that patients receive. Patient satisfaction can include the patient's contentment with overall health care, providers' technical skills, explanation of their problem and treatment options, and the manner in which the provider acts, such as sensitivity and friendliness. Many characteristics of a patient and/ or provider alone; and in combination with factors such as gender, ethnicity, educational level, and other socioeconomic factors, lead to an increase in patient satisfaction (Cooper-Patrick et al., 1999).

Effective communication between the patient and provider is an important contributor to patient satisfaction and strengthens the provider-patient relationship. For effective communication to be present, physicians should listen to the patients and then communicate back, in clear language, their illness and treatment options (Doescher et al., 2000; Sabin & Daniels, 2002). If this communication is impaired, the patient is less likely to comply with medications, follow after care instructions, and come to follow-up appointments (Sabin & Daniels, 2002). Involvement of the patient in his/her health care can increase satisfaction with care. Health care that is closely related to the patients' wants, needs, and preferences may lead to higher levels of satisfaction with the provider (Doescher et al., 2000). Patients who are active participants in their health care (i.e. express their concerns and opinions, ask questions) report a stronger provider/patient relationship and therefore satisfaction with care (Bonds et al., 2004). Trust is another component that plays an important part both in the provider-patient relationship and satisfaction with care (Thorn, 2001; Fiscella, 2004). Caring, communication, and competency are provider behaviors that are strongly associated with patient satisfaction (Schattner et al., 2004).

The United States Head Start program is a national program that promotes school readiness by enhancing the social and cognitive development of children through the provision of early child education, health, nutritional, social and other services to enrolled low income children and families. Though funded by the United States government, Head Start is a group of community-based and community run programs which are child-focused with a main goal to increase the school readiness of young children in low income families.

This study provides data that could contribute to parental education and provider training in child health settings. The study reveals the level of satisfaction that Head Start parents report towards their child's health care, as well as factors associated with such satisfaction. Findings from this study can be used to educate parents on factors that improve their satisfaction with their child's health care. It also could inform health care providers about factors that could improve their relationship with parents in the management of their child's health.


This study's aim is to evaluate the association between parents' satisfaction with a child health care provider's services and: (1) the parent's degree of communication with the child's health care providers; (2) the parent's role in the child's health care; (3) the parent's level of trust towards the child's health care providers; and (4) the parent's ability to voice their concerns regarding the child's health care. It is hypothesized that Head Start parents who report, (1) a higher degree of communication with their child's health care providers; (2) a more active role in their child's health care management; (3) a higher level of trust towards their child's health care providers, and (4) a higher ability to voice their concerns about the child's health to the provider, will report higher levels of satisfaction with their child health care providers.



This is a retrospective study analyzing an existing database; the Health Services Utilization Improvement Model (HUIM) data (Tataw et al., 2007). The data (n = 250) was collected during the implementation of a service grant funded by the California Endowment for the years 2003-2005. Data for this study were derived from the baseline survey collected from parents/guardians of Head Starts children during August-December 2004 by the HUIM program. Surveys were collected from eight out of 21 Head Start sites in South Central Los Angeles.

The Health Services Utilization and improvement Model (HUIM) was a two year program designed to reduce low levels of health services utilization and improve preventive health techniques and disease self-management for Head Start families with the ultimate goal of attaching each child to a medical home. The conceptual predictive model was implemented through educational and case management strategies that address individual determinants of health services utilization as well as provider accommodation (Tataw et al., 2007). The ethnic composition of the Head Start populations for the selected study sites was as follows: 30 percent African American, 68% Hispanic, 1% Pacific Islander, and 1% other.

The Charles Drew University Head Start program is an autonomous community-based program affiliated with Charles Drew University and funded by the US federal government. The service community of the Head Start program covers 124.2 square miles of the County of Los Angeles in the State of California with an estimated population of 1.7 million and the population of children in the service area is estimated at approximately 727,000. The demographics are as follows: 30 percent African American, 67% Hispanic and 3% Asian/Other (U.S. Census Bureau, 2002). Forty percent of the children are at federal poverty level, 95% of the children receive subsidized school lunch, 71% of the residents rent their primary residence, less than 10% have a college education or degree, and 50% have not completed high school (LAC-DHS, 2000). The school children in this area have the lowest scores in Los Angeles County on the Stanford test, and their Scholastic Aptitude Test (SAT) scores are below the district average. Health problems of concern to children in these areas include diabetes, high blood pressure, obesity, asthma, and childhood lead poisoning and low immunization rates (United Way, LA, 2000).

To be able to enroll in the HUIM program, parents/guardians had to meet the following criteria: (1) have a child between the age of 3-5 who was enrolled in Head Start program; (2) reside within the geographic area of South Los Angles; and (3) provide consent signatures or verbal consent indicating that they were aware of the objectives of the program and are willing to be participants. Parents whose children were not enrolled in the Head Start program were excluded from the study, along with those parents who did not sign a consent form. After written consent was obtained, enrolled participants received a 30-40 minutes structured interviewer-administered baseline questionnaire. Both English and Spanish versions of the questionnaire were available and were used as necessary. This study was approved by the Charles Drew University Institutional Review Board.


The selection of variables followed the Behavioral Model for Vulnerable Populations (Harrison, 1996; Johnson et al., 2004)...This is a widely used model for investigating health services utilization among minority populations, originally developed by Andersen (Andersen, 1968; 1995), and colleagues (Harrison, 1996; Johnson et al., 2004; Street, 1992, Flores, Olson, & Tormany-Korman, 2005; Wassmer et al., 2004). This model conceptualizes health care utilization as the end product of a complex pattern of interactions among predisposing, enabling, and need-for-care characteristics. Predisposing characteristics include those factors that describe the propensity of individuals to use health care services (i.e. demographic characteristics, social structural characteristics, childhood characteristics, living conditions, psychological resources, and health belief variables (Harrison, 1996). Enabling characteristics refer to the individual's ability to use health care services, should the need arise (i.e. regular source of care, insurance status, affordability of getting medical care, income, receipt of public benefits, competing needs, and availability and use of information sources (Harrison, 1996; Johnson et al., 2004). Need-for-care characteristics are the most immediate causes of health services utilization. They involve both perceived and evaluated health status (i.e., current health conditions, self-reported health status, and side effects or complications of medical conditions/procedures).


The baseline instrument used to collect the data analyzed in this study measured the following: health services utilization, enabling characteristics, affordability of medical care, regular source of care, and need for care characteristics, voice, and parents' satisfaction with their regular source of care.

Health services utilization (HSU): was measured by seven items. All of them tap formal services received during the past 12 months. Items include: did you take your child/children to a provider for the following reasons; (1) immunization or routine checkup, (2) medical advice or treatment, (3) emergency care, (4) dental care, (5) eye care, (6) hospitalization, and/or (7) specialty care. The mean of the sums of the scores of recorded-items were calculated with higher values interpreted as higher use of services.

Enabling characteristics: were measured using the following indices. The first index, difficulty to access medical care, used a seven item measure on a Likert scale (1 = extremely difficult to 5 = not difficult at all), which included the following questions: Overall, how difficult would it be for you to get the following services for every child in the family (1) routine physical exam; (2) routine eye exam; (3) and, see a health specialist. The second index includes difficulty to (1) get an appointment to see a doctor; and (2) to get an appointment to see a specialist. The third index includes difficulty (1) to get/travel to the doctor; (2) to get/travel to a medical specialist. For each index the mean of the sums of the scores of recorded items were calculated with higher values interpreted as less difficulty.

Affordability of medical care was measured by asking whether during the past 12 months the participants had difficulty getting medical coverage for obtaining (a) eye care, (b) dental care, (c) medical advice or medical treatment, (d) specialty care and/ or (e) prescribed medication? The mean of the sums of the scores of recorded items were calculated with higher values interpreted as having less difficulty.

Regular sources of care: was assessed by asking the participant whether there is "a place you usually take your child/children when they are sick or need medical advice about health?" (1 = Yes, 0 = No).

Need-for-Care Characteristics was measured by: (1) the number of self-reported physical health, mental health, vision, and dental related needs which were perceived by the parent/guardian needing medical advice or treatment during the past 12 months (8 items; 1 = Yes, 0 = No); The mean of the sums of the scores of recorded items were calculated with higher values interpreted as having more need for care; (2) 11 items asking parents about the Well-Child visits and recommended immunization according to the Pediatric Health Examination by the American Academy of Family Physicians. The mean of the sums of the scores of recorded items were calculated with higher values interpreted as "not having the recommended immunization according to the recommendations; and (3) perceived self-rated health status of the child was measured by asking the question, "would you say your child health, in general, is poor, fair, good, or excellent?" with response categories ranging from (1 = poor to 5 = Excellent).

Trust: was assessed by the following question reported in the Likert scale (1= strongly disagree, 5= strongly agree) : I trust my child's/children's regular doctor.

Voice: refers to the parent's ability to voice their concerns and therefore ask questions from their providers regarding the health of their child. Parent/ Guardian's voice was assessed by asking respondents to report in a Likert scale (1 = strongly disagree, 5 = strongly agree) if they can ask and/or talk about the following matters with their child's regular provider: (1) how to prevent child asthma; (2) how to prevent child obesity; (3) ask child's provider to explain child's health care plan in a way a parent/guardian could understand; (4) be very honest and open with the child's provider and express concern if the parent/ guardian has a problem with provider 's advice. The mean of the sums of the scores of recorded items were calculated with higher values interpreted as having stronger voice.

Parents' satisfaction with their child's regular provider: was assessed by asking respondents to report in a Likert scale if they strongly disagree = 1, to strongly agree = 5 with the following statements regarding their child's provider including; (1) "provider being friendly and easy to talk to; (2) provider respecting me and answering all my questions; (3) provider spoke my language; (4) provider spent enough time with me and my child; (5) provider gave my child injury preventive advice; (6) my child's provider cares about us". The mean of the sums of the scores of recorded items were calculated with higher values interpreted as a higher level of satisfaction with the child's provider.

Satisfaction with health care: was assessed by 6 items asking parents/guardians to rate on a scale of 1 (strongly disagree) to 5 (strongly agree) where they stand in their opinion regarding getting "good caring services from the provider" when they used various health care services for their child/children in the past 12 months. The list of health services include obtaining: (1) routine/regular check up; (2) medical advice or treatment; (3) emergency care; (4) dental care; (5) eye care; and (6) hospitalization. The mean of the sums of the scores of recorded items were calculated with higher values interpreted as parent's satisfaction with care received.


We conducted a bivariate analysis to assess the association between "satisfaction with care" and potential covariates using non-parametric t-test (via Kruskal-Wallis) and chi-squared statistic.

Multivariate analyses were conducted to determine the unique importance of each factor --as predictors--with respect to the main outcome, i.e. satisfaction with care. For this purpose we use adjusted logistic regression analysis. All analyses were performed using SPSS version 14.0, 2008). A p-value <0.05 was set as statistically significant and the independent role of predictor variables on the outcome variables were estimated with the odds ratio (OR) and 95% confidence interval (CI).


Table 1 demonstrates the demographics and other variables in the study (n = 250). The majority (88.8 percent) of the subjects were the mother of the Head Start child, with 56.4 percent of the parents/ guardians being married. Ninety percent (91.6%) of the respondents had a regular source of health care, 85.6 percent reported having health insurance for their child, and 50 percent of the children received their regular source of care from either a community provider, Kaiser Permanente health plan, or other HMO.

Table 2 below presents bivariate analysis using independent t-test. On the average, participants reported receiving higher levels of caring service from their providers if they reported: less difficulty to access care [Mean = 14.07; t (df) = -4.32 (243), p = .001] ; less difficulty to travel to receive care [Mean = 9.22; t (df) = 4.06 (240), p = 001]; less difficulty to afford medical care and medication [Mean = 20.4; t (df) = -4.55 (244), p = .007)]; less difficulty to make an appointment [Mean = 9.42; t (df) = -5.42 (240), p = .001)] ; having insurance [Mean = 2.76; t (df) = -3.73 (244), p = .001)]; being satisfied with a child's regular provider [Mean = 33.0; t(df) = -10 (244), p = 001)] ; trusting child's regular provider [Mean = .994; t(df) = -9.02 (239), p = .001]; and having a voice to communicate concerns with the child's regular provider [M = 28.3; t (df)= -9.02 (244), p = .001)].

In Table 3 below, multiple logistic regression is used to identify the independent predictors of "receiving caring services from the provider. " We found that parents who were empowered or having a voice to demonstrate concerns about their child's health to the provider and negotiate care management and plan and ask questions were nearly six times more likely to have reported receiving caring services from their child's providers (OR =5.78; CI= 2.882-11.8, P [less than or equal to] .05). Also, parents who reported trusting their child's provider were eight times more likely to report receiving caring services from their child's providers (OR = 8.63; CI = 9.30-18.1, P [less than or equal to] .05)


This study used retrospective data to determine which variables were associated with parents' self report of receiving caring services from their children's providers. Information obtained from parents relating to the care of their children could provide feedback to providers regarding their personal interviewing style (O'Keefe, 2001). The study assessed the association of communication, trust, and active participation in a child's health care with parents' satisfaction with the health care of their children. Results showed that parents who reported to have voiced their concerns about their child's health were nearly 6 times more likely to report that their child received caring services from their providers than those who did not. As well, those who reported trusting the child's provider were eight times more likely to report that their child received caring services than those who did not.

The results demonstrated that the parent's voice and trust are important factors that contribute to parent satisfaction with the health care that their child receives. Patients tend to give higher ratings to providers who discuss issues with them (Harrison, 1996). A patient's participation in his/her health care has been shown to improve healthcare access among ethnic minorities (Cooper-Patrick et al., 1999). There are community programs that strengthen consumer advocacy skills, in hopes of improving managed care. These programs demonstrate that the consumer's voice can be strengthened through training. In these programs, the patient learns to express his/her opinions and is encouraged to participate in his/her health care plans (Johnson et al., 2004). Parents who asked more questions and expressed more negative affect (e.g. concerns, frustrations) received more information and directives from physicians, and parents who were more expressive elicited a greater amount of feedback from providers (Street, 1992). Also, other studies show a relationship between trust and continuity of care (Hjortdahl & Laerum, 1992; Thom et al., 1998). In this case, patients showed their satisfaction by voting with their feet.

The results of this study provide support for the notion that self efficacy training can contribute to parental satisfaction with health care services. An analysis of the effect of the Health Services Utilization Improvement Model (HUIM) on the same Head Start population involved in this study (Tataw & Bazargan-Hejazi.,2009), revealed that an intervention that combined parental education; non-clinical case management support; and provider training, led to parental self efficacy and satisfaction with a child's health care provider. Indicators of self efficacy were voice and knowledge.


The results of this study underscore the centrality of "voice" in our understanding of the client-provider fit and the provider-related behavior necessary to improve provider accommodation of patients' preferences. The past decade has seen an intensification of the movement to increase the consumer's voice during a medical encounter; in the health care systems; and in health promotion initiatives (Johnson et al., 2004; Street, 1992; Denton et al., 1999; Kenneth, Gingsburg & Menapace, 1997).

The ability of the patient to be heard during a clinical encounter and his/her ability to participate in health decision making is only possible when communication during patient/provider encounters moves from a provider dominated monologue to a dialogue between the provider and patient and there is an exchange of information between provider and patient rather than a transfer of information from provider or expert to patient (Leea, 2003). A dialogue creates space for a patient--provider relationship that nurtures the patient's acceptability of the provider's services through active participation and trusting relationships with providers. This reality calls for provider orientation towards sensitivity to patient's needs and culture, as well as a participatory patient-centered care. Providers should encourage their patients to speak as part of a patient-centered approach (Wassmer, et al., 2004). Also, providers should be encouraged to give the parents a say' in making decisions on their child's treatment. This mutual decision making is a key factor in parental general satisfaction (Galil et al., 2006). Consistent sharing of information has been shown to contribute to both satisfaction and therapy compliance (Counsell, Geddis & Smith, 1993). Other studies show that provider competence, listening skills, clarity and collaboration are predictors of patient satisfaction with competence being the strongest predictor (Moscato et al., 2007). Patients need to be empowered to enter a welcoming space during the medical encounter once providers are appropriately oriented towards patient-centered care. There is a need for parents to be able to trust their child's providers, as well as be empowered to be more vocal in their child's health care. This requires the abandonment of provider dominance during clinical encounters and provider pursuit of a patient centered approach to health care so that space is created for a patient's voice to blossom and trust to develop. This way, patients feel more comfortable to ask questions and to be more involved in their child's health care.

Patient empowerment can also be achieved through education and social support to low income parents. Interventions involving education on prevention and systems utilization strategies; and non-clinical case management support, have been shown to improve self efficacy by increasing knowledge of health systems and preventive health techniques and voice ; as well as improving satisfaction with services (Tataw & Bazargan-Hejazi, 2009). Other studies show that patient knowledge has beneficial effects on satisfaction outcomes (Coombes et al., 2008), and social support is associated with higher levels of self efficacy (Knoll et al., 2009).


The findings in this study should be read in the context of its three limitations. First, the cross-sectional nature of the study data limits our ability to provide more than associational relationship between the study variables. Larger and longitudinal data are needed to clearly identify causal factors that are related to patient's satisfaction with the care. Second, the non-probability nature of the study sample also limits the generalizability of the findings beyond the study population. Third, the lack of data on the ethnicity and gender of the physician of the child's primary health care provider is another limitation in this study. There are many studies which suggest that race/ethnicity and gender of the provider play an important part in patient satisfaction and physician trust (Cooper-Patrick et al., 1999; Thiel de Bocanegra & Gany, 2004).


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David Besong Tataw, PhD

Shahrzad Bazargan-Hejazi, PhD

Priya Patel, MD

Dr David B. Tataw, MMIS, MPA, PhD, is affiliated with Indiana University Kokomo, Charles R. Drew University, Los Angeles, and The Institute for Health Policy and Systems Effectiveness. E-mail: dbtataw@yahoo.com. Dr. Shahrzad Bazargan-Hejazi, PhD is affiliated with Charles R. Drew University and David Geffen School of Medicine at University of California at Los Angeles (UCLA) The Institute for Health Policy and Systems Effectiveness. 1731 120th Street, Los Angeles, CA 90059. Phone: 323-357-3464. E-mail: shbazarg@cdrewu.edu. Priya Patel, MD, is affiliated with Long Beach Memorial Children's Clinic. 525 E Seaside Way Unit 303. Long Beach, CA 90802. Phone: (562) 715-7857. E-mail: pvpatel@hotmail.com
Table 1: Demographic and Other Predisposing and
Enabling Characteristics (n = 250)

Variable                       Category          f (%)

Relation to child               Mother         222 (88.8)
                                Father          23 (9.2)
                                 Other          5 (2.0)

Person making HC                Mother         217 (86.8)
  decisions                     Father         25 (10.0)
                                Other           5 (3.2)

Marital Status                   Married        141 (56.4)
                              Not Married       105 (43.6)

Live at present address        Up to 5 yrs      146 (58.4)
                              6 yrs or more      70 (41.6)

Regular Source of Care            Yes           229 (91.6)
                                  No             10 (4.0)

Health Insurance                  Yes           214 (85.6)
                                  No             19 (7.6)

Access to Regular                 Yes           237 (94.8)
  Source of Care                  No              7 (2.8)

Child's Health Status            Poor             3 (1.2)
                                 Fair            15 (6.0)
                                 Good           115 (46.0)
                              Excellent         106 (42.4)

Location of regular       Doctor/Kaiser/HMO     125 (50.0)
  care                     Clinic/Hospital      114 (45.6)
                              ER/Other            6 (2.4)

Table 2: Bivariate Analysis using Independent Sample

Variables            Receiving      Receiving      t (df)        P
                        low           high                     Value
                       caring        caring
                      service        service
                      Mean(SE)      Mean (SE)

Knowledge of        6.21 (.171)    6.33 (.100)   -.618 (227)    NS
  access to
  health care
Child meeting       9.72 (.322)    9.87 (.224)   -.262 (232)    NS
Utilization of      3.25 (.236)    3.38 (.124)   -.53 (240)     NS
  health care
Number of child's   .683 (.930)    .621 (1.08)    .404(241)     NS
  health problems
Difficulty to       12.75(.343)    14.07 (.135)  -4.32 (243)   .001
  access care
  (routine, eye,
Difficulty to       8.12 (.323)    9.22 (.112)   -4.06 (240)   .001
  travel for care
Affordability to    16.93 (.676)   20.4 (.386)   -4.55(244)    .007
  get medical
  dental and eye
  care due to
  payment from
  your pocket
Difficulty to get   8.17 (.288)    9.42 (.092)   -5.42(240)    .001
  (primary care,
Source of           1.31 (.104)    1.23 (.052)    .73(244)      NS
  used to find
   provider for
  the child
Insurance           2.30 (.145)    2.76 (.052)   -3.73(240)    .001
  dental, eye)
Satisfaction with   25.6 (.982)    33.0 (.247)    -10(244)     .001
  the child's
  regular doctor
Trusting child's    .803 (.051)    .994 (.005)   -6.11(239)    .000
  regular doctors
Voice               22.3 (.842)    28.3 (.256)   -9.02(244)    .000
Perceived health    3.36 (.081)    3.34 (.050)    .23(235)      NS
  status of the

Table 3: Multivariable Analysis using
Multiple Logistics

Variable                              [OR.sup.ab]     95% CI

Utilization of health care services     1.23       .606-2.52
Difficulty to access care               1.29       .527-3.18
Difficulty traveling to get care        1.25       .535-2.93
Difficulty getting appointments         1.83       .766-4.39
Insurance                               1.40       .908-2.16
Voice                                   5.78       2.88-11.8 *
Number of health problems               .732       .363-1.47
Trust                                   8.63       9.30-18.1 *
Marital status                          .989       .779-1.29
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