1992; Short and Lefkowitz, 1992; Woodward et al., 1988), an inability to read outreach and other health-related materials (Riportella-Muller et al., 1996), and a lack of skills related to care taking, including a lack of knowledge about prevention and health care needs (Margolis et al., 1995; Newacheck, 1989; Riportella-Muller et al., 1996). Routine preventive services are sometimes neglected for children with chronic health problems and special health care needs (Riportella-Muller et al., 1996).

Low-income parents may be more likely to experience logistical difficulties in arranging care, such as a lack of transportation and lack of a telephone to arrange appointments (Fossett et al., 1992). Regardless of income, parents may have trouble arranging health care appointments because of a lack of child care for siblings or other family members (Riportella-Muller et al., 1996) and difficulty in taking time off from work (Riportella-Muller et al., 1996; Wolfe, 1980).

Family structure also relates to health care access. With the exception of children of young teenage mothers who live with their own mothers (Short and Lefkowitz, 1992), first-born children, only children, and younger children tend to have more outpatient visits (Cafferata and Kasper, 1985; Horwitz et al., 1985; Newacheck, 1992).

Parental health problems or other personal problems and family crises also can compete with children's health care needs as priorities for parental attention (Riportella-Muller et al., 1996). Families who have health and social problems may be less likely to seek health care for a child when it is needed.

Race, Ethnicity, and Cultural Factors

In the increasingly diverse U.S. society, the influences of racial, ethnic, and cultural factors on access to care are gaining a greater degree of recognition. Several studies have shown that nonwhite children have fewer physician visits than white children (Cornelius, 1993; Newacheck, 1992; Wolfe, 1980), independent of the need for care (Horwitz et al., 1985; Riley et al., 1993). Even with insurance coverage, minority adolescents have fewer visits to physicians, are less likely to have a usual source of care, and lack continuity of care in comparison with non-Hispanic white adolescents (Lieu et al., 1993).

Black and Hispanic children are more likely to live in poverty (46.4 percent of black and 39.7 percent of Hispanic children) than white children (12.2 percent). They are also more likely than white children to be uninsured (15.3 percent of black children and 26.8 percent of Hispanic children compared with 10.5 percent of white children in 1995 (see Figure 2.5).

Compared with the distribution of racial and ethnic groups in the U.S. population, there is a shortage of African-American, Hispanic, and Asian-American physicians and other health professionals (Lewin-Epstein, 1991). Health care services are often located outside of a racial or ethnic neighborhood. In areas where there is segregation or racial tension, this may increase an individual's reluctance to seek care outside of the neighborhood (Fossett et al., 1992).

Children with asthma are more likely to require hospitalization (an indicator of ineffective outpatient care) if they are poor, black, or Hispanic, and the outcomes of treatment are often worse (Carr et al., 1992; Perrin et al., 1989; Wissow et al., 1988). For example, a study in New York City found that poor black and Hispanic children who were hospitalized for asthma were three to six times more likely than white children to die from the episode, and also tended to come from lower-income families than the white children (Carr et al., 1992).

Cultural factors also influence care-seeking behaviors. A study of African Americans, Mexican Americans, Puerto Ricans, and non-Hispanic whites in poor areas of Chicago found that African Americans tended to use hospital-based facilities, while Mexican Americans were the least likely of all the groups to have a regular source of care, in large part because of social and cultural barriers such as language and immigration status (Lewin-Epstein, 1991). Hispanics with traditional health beliefs and health care practices may not perceive a need for health care, especially for preventive interventions (Andersen et al., 1986). Southeast Asians who believe in the inevitability of suffering and the

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