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Underinsurance Study

Overview: While considerable attention has been focused on uninsured children/families, there are many families who are unable to afford recommended care for their children even though they are insured. This SOAR-Net study represented a modification of a study by Colorado family physicians (Voorhees, Fernald, Emsermann, et al. 2008) that was published in the Journal of the American Board of Family Medicine. The study focused solely on adults while the SOAR-Net study focused on children’s health care. Parents were surveyed to assess whether (in spite of having insurance) they had delayed or avoided medical care (prescriptions, labs, x-rays, sub-specialty appointments, medical supplies, etc.) for their children due to poor insurance coverage of these services or because of high deductibles or co-pays. Data collection for this study was completed in September 2009.

Findings: Parents reported that 17.2% of their children were underinsured as evidenced by their inability during the last year to pay for at least one of the recommendations made by their child’s pediatrician. In addition, 15.5% of parents reported it was harder to get medical care for their child in the past 3 years and 6.5% believed their child’s health had suffered.

Conclusion: It is possible that high deductible features of insurance plans contributed to parents’ inability to secure needed medical care for their children.

Peer-reviewed articles and presentations:

Spears W. Pascoe J. Khamis H. McNicholas C. Eberhart G. Parents’ perspectives on their children’s health insurance: plight of the underinsured. The Journal of Pediatrics. 162: 403-408, 2013.

Parents’ Perspectives on their Children’s Health Insurance: Plight of the Underinsured

Social Capital Study

Overview: SOAR-Net clinicians from community pediatric offices in the Dayton-Miami Valley area recruited more than 700 parents to participate in the Social Capital Study. Sites included: The Rocking Horse Center (Springfield, OH), Cornerstone Pediatrics (Springboro, OH), Ohio Pediatrics, Inc. (Kettering and Huber Heights, OH locations) and the Developmental Pediatric Clinic at the Dayton Children's Hospital of Dayton. Parents were invited to answer questions about the health and quality of life of their children and their own community support, or social capital. The overwhelming response from parents concerning content of the questionnaire has been positive. Twelve-month reviews of the “index” child’s medical chart were conducted to determine parent and child health behaviors (e.g. office phone calls, immunizations, well and acute visits). A Body Mass Index (BMI) was also collected for each index child. Chart reviews were completed in September 2009.

Findings: Mothers who reported less social capital were more likely to have lower education and income and higher levels of depression. It was not possible in this study to establish causation, that is, did higher levels of depression lead to perceived lower levels of social capital or was the lower level of social capital causative of depression.

Conclusions: The social capital scale used in this study may be a new useful tool for investigators and clinicians who work with children and their parents. The relationship between depression and social capital needs to be explored further.

Peer-reviewed articles and presentations:

Pascoe J. Specht S. McNicholas C. Kasten E. Spears W. Looman W. Correlates of mothers’ perception of their communities’ social capital: a community-based study. Maternal Child Health Journal. 17: 1382-1390, 2013.

Geographic Variation in Parents’ Perception of Their Communities’ Social Capital and Associated Factors

A New Social Capital Scale: Geographic Stability Compared to Mothers’ Personal Support and Depressive Symptoms

Maternal Mental Health Study

Overview: SOAR-Net clinicians participated in the Maternal Mental Health Study along with members of the Ohio Research Consortium. The goal of the study was to improve health care providers’ awareness of maternal depression and to increase screening and referrals of mothers who are at risk for depression. In order to assess the appropriateness of a maternal resource guide that listed services for depression the mothers of over 1,000 SOAR-Net patients were asked to complete a two-page survey providing feedback on the guides. The response from participating mothers was overwhelmingly positive.

Findings: Mothers were more likely to report that “This guide is helpful to me” if they were single, their child had public health insurance, or they, mothers, had a positive screen for depression. After controlling for demographic variables, the positive screen for depression was still associated with perceived helpfulness of the guide.

Conclusion: Mothers experiencing signs of depression affirmed the usefulness of a guide describing community mental health services.

Peer-reviewed articles and presentations:

Pascoe J. Lee M. Specht S. McNicholas C. Spears W. Gans A. Heneghan A. Mothers with positive or negative depression screens evaluate a maternal resource guide. Journal of Pediatric Health Care. 24(6): 378-384, 2010.

Civilian and Military Mothers Evaluate a Mothers’ Resource Guide

Correlates of Mothers’ Persistent Depressive Symptoms: A National Study

Overview: Mothers’ depressive symptoms are common and adversely affect their attitudes and competence (Cox, Puckering, Pound, & Mills, 1987; Hall, Gurley, Sachs, & Kryscio, 1991; Lutenbacher & Hall, 1998; Weissman et al., 1986). Children of mothers with depressive symptoms have been shown to exhibit significant physical problems. The purpose of this study was to examine the prevalence, persistence, and correlates of mothers’ depressive symptoms over a 5-year period in a nationally representative sample of the United States population.

Findings: One fifth of study mothers (n=2,235) had positive results on a brief depression screening instrument, the Center for Epidemiological Studies Depression Scale (CES-12). Risk factors for persistent positive scores were being less than 30 years old, African-American, never married or divorced, indigent, and having less than a high school education. Being unmarried more than doubled the likelihood that a woman would have a persistent positive score, AOR = 2.60, (1.89-3.56).

Conclusion: This study corroborates earlier work that documents the high frequency of depressive symptoms in U.S. mothers. Data also suggest that depressive symptoms are more common in mothers younger than 30 years of age, presumably with younger children at home. Further research should focus on methods for engaging these mothers in care.

Peer-reviewed articles and presentations:

Pascoe J. Stolfi A. Ormond M. Correlates of mothers’ persistent depressive symptoms: a national study. Journal of the American Board of Family Medicine. 20(4): 261-269, July/August 2009.

Mothers’ Persistent Depressive Symptoms and Their Preschool Children’s Math: A Study

Parents' perception of their child's weight status and communication with their child's pediatrician

Overview: Parents’ accurate perception of their child’s weight enables them to help their child achieve and maintain a healthy weight. Regardless of socio-demographic background and parental education levels, previous studies have reported that effective communication between parents and pediatricians help promote healthy childhood weight. This cross-sectional study was designed to assess parents’ perception of their child’s weight status and to determine if pediatricians discuss either BMI or overweight status with parents during office visits. The hypothesis of this study is that parents who estimate their child’s weight more accurately are more likely to discuss topics related to their child’s weight with their child’s pediatrician. The project site was a primary care pediatric office within in the Southwestern Ohio Ambulatory Research Network (SOAR-Net); a regional practice-based research network. Conducted between September 2010 and October 2012, 567 parents with a child between age 2 and 18 years old completed surveys during a visit to their pediatrician’s office. Children’s weight and height were measured during the office visit. The survey included two questions regarding conversations with the child’s pediatrician: 1) Has the child’s pediatrician ever discussed the child’s weight status or BMI; 2) Has the child’s pediatrician ever stated that the child was gaining weight too fast or was overweight or very overweight. The term “obese” was not included in the survey. Parents were asked to respond to a Likert scale regarding their perception of their child’s weight status from underweight to very overweight. Parents were also asked to select the most accurate depiction of their child’s body shape from a series of silhouettes of children’s bodies.

Findings: Of the 470 children in the study sample, 31.7% were overweight or obese. BMI-for-age 59 and parental perceptions of child weight using silhouette and a Likert Scale were then cross-tabulated with pediatrician’s comments about BMI or overweight status. More than 65% of parents (n=307) responded that their child’s pediatrician had discussed BMI-for-age regardless of their child’s weight status (p=0.249). However, only 58 (12.3%) parents responded that their child’s pediatrician had mentioned the child was overweight or gaining weight too fast (p<0.001). Approximately 49% (n=223) of study parents underestimated their child’s weight status using silhouettes. Very few parents (2.6%) overestimated their child’s weight status using silhouettes. There was no association between parental perception using silhouettes and conversation with pediatricians about BMI (p=0.249). Parental perception of their child’s weight using silhouettes was associated with parental recall of conversation with their child’s pediatrician about overweight status (p=0.061).

Conclusions: Earlier research suggests that parents who underestimate their child’s weight are less likely to address their child’s overweight/obesity problem. In this study, about a quarter of parents of overweight children, and 40% of parents of obese children reported that their child’s pediatrician commented on their child’s overweight status. This compares to national estimates of less than one-quarter of parents with overweight/obese children report having been told that their child was overweight. 103 Parents’ failure to recall or understand their child’s pediatrician’s comments regarding their child’s unhealthy weight may contribute to their underestimate of their child’s weight status.

Parent Pediatrician Partnership Survey—Phase 1

Overview: The Parent Pediatrician Partnership Survey was developed by SOAR-Net investigators to help pediatricians and other child health clinicians understand the factors that parents find important while interacting with their child’s pediatrician. Twenty-four pediatricians and over 190 parents from two SOAR-Net practices were asked to rate the importance of sixty-one concepts that addressed different aspects of partnership. This approach to scale development provided investigators with the opportunity to understand: (1) how physicians and parents viewed partnership and (2) how two socioeconomically different groups of parents viewed partnership with their child’s pediatrician. Parents from the two practices were compared using psychosocial screening instruments that assessed the presence of alcohol abuse, depression, social capital and domestic violence.

Findings: There were major differences between parents in the two clinics on characteristics such as parent education and family income, as well as rates of domestic violence and mothers’ binge drinking. Children in one of the clinics were more likely to be on public insurance and qualify for an individualized education program in school.

Twenty-six of the sixty-one concepts were endorsed as “very important” to partnership by pediatricians and by parents from both of the two SOAR-Net practices. Five concepts were endorsed as important to partnership by both groups of parents, but not by pediatricians; these items centered on practical considerations such as availability of care, amount of time spent with child, pediatricians’ interaction with other professionals and the importance of parents agreeing with pediatricians on a treatment plan. Seven items were seen as relatively unimportant to less affluent parents but important by more affluent parents and by pediatricians. Less affluent parents appeared to put less emphasis on getting reassuring information, having active involvement in making recommendations or defining the problem, receiving advice on how to stay healthy in the future or having children involved in these tasks. Thirty-eight items were retained for inclusion in the Parent Pediatrician Partnership Survey (PPPS).

Conclusions: There was a pool of concepts that pediatricians and all parents agreed were very important to forming a partnership, these items made-up 46.2% of all items. There were also items that both groups of parents saw as equally important in contrast to pediatrician’s views. Possibly, most surprising were the similar views of importance between affluent parents and pediatricians, primarily on items that related to the degree with which parents were involved in their child’s care.

Peer-reviewed articles and presentations:

Understanding Perspectives on Partnership: The Parent Pediatrician Partnership Survey (PPPS)

Parent Pediatrician Partnership Survey—Phase 2

Overview: This study was conducted as the second phase in the development of the Parent Pediatrician Partnership Scale.  Our objective was to identify the latent factor structure among thirty-eight items relating to partnership between parents and pediatricians and identify the parent/child and setting characteristics that were associated with each factor.

Methods: Thirty-eight partnership items from Phase 1 were administered to 1,074 parents. Nine items were eliminated from the original 38-item pool based on parents’ confusion about what the items meant. The remaining 29 items were entered in a factor analysis that produced four well-defined factors.

Findings: The sample population was predominantly White (80.4%), had at least some college education (77.1%), the child was brought to the index appointment by a guardian living in a married relationship (70.2), and the index child was male (55.5%). Three-quarters (74.4%) of parents were interviewed in a community practice (n=799) and the remainder in sub-specialty clinics located in a children’s hospital (n=275).

Factors included Sensitivity (Se, 10 items), Collaboration (Co, 6 items), Education (Ed, 8 items), and Access (Ac, 5 items). Examples from each of the factors are as follows: Sensitivity - My pediatrician treats my child and me with dignity; Collaboration – My pediatrician involves me in defining the problem; Education - My pediatrician clearly explains what the treatment is; and Access - I have easy access to my pediatrician’s office. Using correlations, t-tests, and regression analyses parent/child characteristics and their use of treatment setting were examined for a possible bivariate relationship with each factor. Only 3 characteristics—fewer children having been to the practice, having seen the same physician for the past year and attending a subspecialty clinic—had robust associations with all factors. Regression analyses showed that having seen the same physician during the past year had the strongest association with higher scores on each factor.

Conclusion: Among characteristics included in this study, only an exclusive relationship with a pediatrician led to higher partnership scores. This finding should be noted by pediatricians in all settings, parents working with a single pediatrician may develop a stronger sense of partnership. Additional studies should be conducted to identify additional parent and setting characteristics that are related to partnership.

Peer-reviewed articles and presentations:

Understanding Partnership: Factor Structure of the Parent Pediatrician Partnership Scale (PPPS)

The Influence of Practice Setting on Factors in the Parent Pediatrician Partnership Scale (PPPS)

Health Literacy

Overview: Prior studies have linked low health literacy to increased hospitalization and increased utilization of emergency department (ED) care. Adult studies have demonstrated that adults with lower health literacy have a decreased understanding of discharge instructions in an ED setting. The primary objective of this study was to determine whether health literacy was associated with parents’ ability to remember discharge instructions following their child’s hospitalization. A second objective was to identify other characteristics that might be associated with the recall of three categories of discharge instructions: 1) diagnosis, 2) name of prescribed medication(s), and 3) dosage of the prescribed medication(s).

Methods: One hundred and sixty-five (165) parents were asked to participate in a study of health literacy at Dayton Children’s Hospital between 2012 and 2014, all but 10 parents, 94%, agreed to do so; 4 surveys were not completed. The remaining 151 parents completed a survey that included an assessment of their health literacy immediately prior to their children being discharged. Follow-up telephone calls were completed with 88 of the parents (58.3%) following their child’s release. Parents were asked to recall home care information they received at the time of their child’s discharge from a pediatric hospital. Information included their child’s diagnosis, name of any medication(s), and the prescribed dosage of each medication. Retrospective chart reviews were conducted to collect corresponding physician diagnoses and medication information.  Two pediatricians rated the congruence between parent’s recall and medical record entries. Congruence was rated as exact, partial or not present.

Findings: Health Literacy (Objective #1): There was no association between health literacy and parent recall of presenting problems, medications, or medication dosage. Health literacy was associated with having public health insurance vs. private (p = .000),being African American vs. Caucasian (p = .002), and <= high school education vs. having some college education (p = .000). Parental Recall (Objective #2): After discharge, 46.6% (n = 41) of parents exactly identified at least one of their child’s presenting problems, 61.3% (n = 54) correctly identified at least one of their child’s medications, and only 24.2% (n = 21) were able to correctly recall the dosage for at least one medication.

Conclusions: One of the most important physician-patient interactions is the hospital discharge process. The discharge instructions guide the patients when they are no longer under a physician’s supervision. Without the supervision of a physician, patients are more likely to make errors, placing them at risk for considerable morbidity, including disease recurrence and other negative outcomes. Our results demonstrate the magnitude of breakdown in patient-physician communication. Most concerning is the lack of understanding of medication dosage, likely contributing to medication mismanagement and adverse outcomes for the patient. The ability to exactly match discharge instructions was not influenced by health literacy. Improved parental understanding of medicine instructions and administration would have the potential to reduce a large proportion of the preventable adverse outcomes and disease recurrence.

Peer-reviewed articles and presentations:

Association Between Parental Health Literacy and Discharge Diagnosis for Recently Hospitalized Children

Mental Health Referral

Overview: Studies have found 10% to 25% of pediatric patients experience mental health disorders, but many of these children remain undiagnosed and untreated. Due to the increasing prevalence of pediatric mental health disorders, diagnosis and subsequent care of these patients becomes the responsibility of the pediatrician. With this shift, pediatricians have reported the increased need for advice and input from mental health care specialists, especially for more complex psychiatric conditions and administration of psychotropic medications. The objective for the current study is to identify the specific role pediatricians and parents play in the diagnosis, treatment and referral process for children with behavioral health care needs. 

Methods: Researchers in the Department of Pediatrics at Boonshoft School of Medicine developed the Mental Health Referral Survey (MHRS) to understand the parent and child characteristics that might be associated with how pediatricians treat patients if behavioral concerns are brought to their attention, and how pediatricians refer patients to further specialty care. Survey questions were divided into initial behavior recognition and diagnosis, pediatrician awareness of behavior concerns with subsequent treatment and referral practices, parent self-referral including barriers experienced, and socio-demographic characteristics. Parents were presented with a list of specific behaviors that could indicate a behavioral health problem.

Findings: Preliminary results come from parents who had brought their children to two pediatric practices in Southwest Ohio. Four hundred and nineteen (419) parents were asked to participate in the Mental Health Referral Study; almost ninety percent (86.4%, n = 362) of parents agreed to participate. One hundred and thirty seven (137) parents (37.8%) affirmed at least one of the potential behavioral health care needs, most frequently hyperactivity, trouble sleeping, anger, loss of interest, inability to finish tasks, and defiance. One hundred and twenty five (125) completed surveys were obtained.

Children in the study were White (79.2%), male (50.4%), covered by some form of public health insurance (64.8%), and a mean age of 9.9 years. Parents tended to be in a married-like relationship (64.8%), have a household income greater than $35,000 (69.6%), and have a mean age of 39.2 years and completed 14.9 years of school. Parents and their children had attended their pediatrician’s practice for 8.0 years and saw an average of 3.0 different physicians at the practice. Fifty-seven (45.6%) of the children had received at least one formal diagnosis.

Parents who told their pediatricians about their child’s behavioral health care need (n = 87; 69.6%) were younger (mean age 38.0 versus 41.6) and were less likely to have been the first person, compared to a professional, to recognize the behavioral health care need (55.2%). Their children had at least one formal mental health diagnosis (63.2%), were male (56.3%), and had an IEP (36.8%). These patients saw fewer pediatricians at their group practice (mean 2.8 versus 3.4).

Pediatricians who were told about a child’s BHCN referred only about one-third (30.0%) of the parents to a mental health service. Referred parents and children differed from non-referred parents and children in that the former group was made up of older children (11.1 vs. 9.5 years old) and were much more likely to have a child with at least one formal diagnosis (88.5% vs. 52.5%). Parents referred to mental health services by their pediatrician made a telephone call to the referral location 42.3% of the time and all eventually attended a first face-to-face appointment. Among parents not referred by their pediatrician, 15 (24.6%) called a mental health service on their own initiative and all but two attended a face-to-face appointment.

Conclusions: Preliminary analyses of data revealed three themes. First, almost 70% of parents told their child’s pediatrician about the presence of a behavioral health care need. Parents whose child had a formal diagnosis and who saw fewer pediatricians at a practice were more likely to have told. It is possible that familiarity with a particular pediatrician provided the parent with the impetus to tell them about the behavioral health care need. Second, pediatricians referred only 30% of the children with BHCN to any specialty care. Given limited sample size we were not able to identify possible reasons for the low referral rate. It is possible that non-referred children had less serious needs and the pediatrician treated them within their practice. Third, the importance of pediatrician involvement is demonstrated in the finding that among children who were referred by a pediatrician
42.3% at least made a telephone call to the specialty service. Among parents not referred by their pediatrician only 24.6% called a mental health service.

Peer-reviewed articles and presentations:

Pediatricians’ Role in the Behavioral Health Care Referral Process

Pediatricians’ Referral Patterns for Children with Behavioral Health Care Needs (BHCN)

Children and Firearms in the Home

Overview: To ascertain the prevalence of gun ownership, gun safety education, and parental attitudes on gun counseling in a Midwestern sample.

Methods: Parents seeking care at participating practices in the Southwestern Ohio Ambulatory Research Network (SOAR-Net) were recruited to complete a survey about gun ownership, gun safety education, and gun counseling attitudes. Attitudes and beliefs were compared between gun owners and non-gun owners.

Findings: Twenty-four percent of respondents had at least 1 gun in the home. Military families were more likely to own a gun than civilian families (28% vs. 18%, p = .001). Fifty-two percent of sample children had received gun safety education. Eight percent indicated that physician had asked about guns or discussed gun safety issues during an office visit. A majority of parents indicated that physicians should ask about guns in the home (69%) and advise parents on safe storage (75%), but they should not advise parents to remove guns from the home (12% of gun owners, 42% of non-gun owners.

Conclusions: Despite the morbidity and mortality associated with guns, physicians in this study to not seem to be addressing this risk with families. A majority of owners do not agree that physicians should counsel the removal of guns from the home but agree that they should discuss safe gun storage information.

Peer-reviewed articles and presentations:

Forbis S. McAllister T. Monk S. Schlorman C. Stolfi A. Pascoe J. Children and firearms in the home: A Southwestern Ohio Ambulatory Research Method (SOAR-Net) Study. Journal of the American Board of Family Medicine. 20:385-391, 2007.

Patient Visits to a Midwestern Primary Care Practice-Based Research Network

Background: Regional primary care practice-based research networks (PBRNs) have made important contributions to the primary care literature, but have not been well-described. This study compares pediatric patient characteristics with a new regional PRBR to pediatric patient characteristics from two previously published national data sets. 

Methods: Descriptive patient data were collected by 25 Southwestern Ohio Ambulatory Research Network (SOAR-Net) clinicians between July 2003 and June 2004. These data were compared to pediatric patient characteristics from 57 Pediatric Research in Office Setting clinicians and 33 primary care pediatric clinicians who participated in the National Ambulatory Medical Care Survey.

Results: SOAR-Net patients were almost twice as likely to use Medicaid (41.9% vs. 22.0%/22.4%, p = 0.00001. SOAR-Net patients also were more likely to be African-American (23.7% vs. 7.5%/17.6%, p = 0.002). About one third of patients in each sample were seen for a well visit.

Conclusion: Regional networks with unique characteristics, such as a large number of Medicaid patients and/or many underserved minority patients have the potential to make significant contributions to primary care research by focusing on problems experienced within those segments of a population (e.g., indigent children and their families).


Additional Publications and Presentations


Pascoe J. Little D. Forbis S. Slora E. Patient visits to a Midwestern primary care practice-based research a comparison to two national primary care data sets. Southern Medical Journal. 101(7): 693-698, 2008.


Parents’ Perception of Their Children's Asthma, 2002-2008: A Community-Based Study

Parents’ Annual Income/Marital Status and Their Community Connectedness: A Cross Sectional Study