Indigenous Health Article Ethnic and Indigenous access to early childhood healthcare services in Australia: parents’ perceived unmet needs and related barriers Lixin Ou, Jack Chen Abstract Objective: To evaluate the parents’ perceived unmet needs in early childhood healthcare services among Indigenous, non-English-speaking background (NESB) and English-speaking background (ESB) children and the related barriers. Method: Data was from the Longitudinal Study of Australian Children (LSAC). RaoScott chi-square was used to examine the level of parents’ perceived unmet needs in three ethnic groups in early childhood healthcare services over a 12 month period. Survey logistic regression was used to assess the association between the groups of infants and the barriers to utilisation. Results: Ten per cent of Australian infants have at least one parents’ perceived unmet need in early childhood healthcare services. NESB (15.3%) and Indigenous (15.1%) infants were more likely than ESB infants (9.9%, p<0.001) to have parents’ perceived unmet needs in health care services. The barriers to service access include cost, transport problems, child care difficulties, service availability and family reasons. Parents of ESB infants were more likely to cite operating hours as the major barrier to accessing services. Conclusion: There were parents’ perceived unmet needs in a number of health services for all Australian infants, but at different levels by Indigenous, NESB and ESB groups. The most common barrier to services utilisation related to cost or private health insurance, availability and accessibility of service provision and other socioeconomic issues. Implications: Policy attention and operational changes are required to improve equity in accessing early childhood services, as well as to improve the overall access to healthcare services for all Australian infants. Key words: health services, utilisation, disparity, barrier, early childhood. Aust NZ J Public Health. 2010; 30-7 doi: 10.1111/j.1753-6405.2010.00633.x 30 The Simpson Centre for Health Services Research, University of New South Wales Pamela Garrett New South Wales Refugee Health Plan, Sydney South West Area Health Service Ken Hillman The Simpson Centre for Health Services Research, University of New South Wales P erceived unmet needs for health services is the most commonly used approach to indicate access problems with identified populations by measuring the degree of perception of needs for health services that are not received.1 In child health services research, parents’ or carers’ perceived unmet needs are often used to measure the degree of access problems.1,2 Given that equity in health services has been defined as equal access to available care for equal need, equal utilisation for equal need, and equal quality of care for all,3 unmet needs in access to health services may, in turn, lead to unequal utilisation of health services, and play a critical role in causing inequity in health services. For example, the higher degree of unmet healthcare needs among racial or ethnic minorities, in accordance with the concept of equity in health services, may indicate inequitable use of health services by race or ethnicity.4 The factors influencing racial and ethnic disparity in child healthcare access have frequently proved elusive, with much research and scholarly attention focusing on proving ethnic disparity and relatively less on understanding the complex interaction of factors contributing to healthcare inequity and ultimately poorer health outcomes. Certainly international research indicates Submitted: February 2010 there are unmet needs in child health service access.5-8 Failure to access health services and obtaining early health interventions for children with health care needs can result in inadequate use of health care, poor health status in early childhood, and negative health outcomes and wellbeing in later childhood or adulthood.9 There is evidence to support the views of the foetal origins of adult disease and better return on investment by intervening in the early years.10 Given that the health gap emerges in early childhood and the influence of early childhood experience can last over a lifetime, it has been emphasised that intervening early in the life course can eff iciently reduce the health risks throughout lifetime. 10,11 A very recent strategic review of Health Inequalities in England Post 2010 provided two out of six policy recommendations relating to children for the purpose of closing the gaps in early childhood and giving every child the best start in life.12 Understanding barriers in access to health services among different populations is crucial to reduce health status inequity and to improve quality and safety of health care.13 Recent international literature reviews have demonstrated that the major access barriers include lack of health insurance coverage, Revision requested: April 2010 Accepted: July 2010 Correspondence to: Lixin Ou, The Simpson Centre for Health Services Research, The University of New South Wales; e-mail: Lixin.Ou@sswahs.nsw.gov.au; Lixin.ou@unsw.edu.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 2011 VOL. 35 NO. 1 Indigenous Health Ethnic and Indigenous access to early childhood healthcare socioeconomic disadvantages, cultural traditions, lack of available resources, racial or ethnic differences and language-related barriers.4,13,14 Other studies reported barriers in relation to transport issues, long waiting times and factors related to parents.15,16 A national health survey in the US revealed that children from racial/ ethnic minorities were more likely to have unmet health needs, to experience access barriers, and to have poorer health services utilisation than children from ethnic majorities.8 These disparities mirror socioeconomic status, employment, education, insurance status and environmental difference.17 In Australia, our recent studies have found that Indigenous and non-English speaking background (NESB) infants were significantly less likely than English speaking background (ESB) infants to use a range of health services, which included maternal and child health centres or phone help, maternal and child health nurse visits, general practitioners (GPs), and paediatricians.18,19 Other studies confirmed that children from vulnerable populations, such as racial/ethnic minorities and socioeconomically disadvantaged groups, are more likely to experience barriers to accessing appropriate health care.20-23 However, these studies have been performed either at a state or community level; or with children having a specific health care need or condition. The capacity to generalise conclusions, therefore, has been limited. Although it is well known that the mortality rate of Indigenous infants is almost three times higher than the rate of non-Indigenous infants; Indigenous infants are almost twice as likely to be preterm or of low birth-weight, as well as having a higher pre-natal mortality compared with non-Indigenous infants,24,25 the level of unmet needs for health services and access barriers in childhood’s health services utilisation across ethnic and racial minority children in Australia remains unclear. The Longitudinal Study of Australian Children (LSAC)26 tracks two randomly selected national representative cohorts of children: those aged 3-18 months and those aged 4-5 years. The LSAC investigates the health, social and emotional wellbeing of Australian children, and provides an opportunity to examine the impacts of Australia’s unique social structure and cultural environment on the next generation.26,27 The present study using the LSAC data aimed to 1) evaluate parents’ perceived unmet needs in access to health services among Australian infants by Indigenous, NESB and ESB infants; 2) identify the major barriers preventing their access to the needed health services. Methods Study design and sampling Data was drawn from the first wave infant cohort (3-18 months old) of the LSAC. The sampling design and its methodology have been described in details elsewhere.28 Briefly, the first wave interviews of the LSAC were conducted between March and November 2004 with a two-stage stratified, clustered sample design. The sample frame of the LSAC was selected from the Health Insurance Commission (HIC) Medicare database. The sample elements were firstly stratified by state or territory and 2011 VOL. 35 NO. 1 then by urban or rural status. Within each of the strata, about one out of the 10 Australian postcodes was randomly included in the study as the primary sampling units to ensure proportional geographic representation. Within 311 selected postcodes, infants born from March 2003 and February 2004 were selected at random by the HIC. Of the 9,259 selected infants, 7,951 families could be contacted as residents within those postcodes, and of these families, 5,107 (64.2%) were recruited to the LSAC study. Only one child per family was recruited to the LSAC. Data collection Trained professional interviewers undertook a two-and-halfhour face-to-face interview with the primary care-giving parent, mostly the biological mother. The respondents also completed a written questionnaire as part of the main interview. For each participating child, written consent was obtained. The study was approved by the Australian Institute of Family Studies Ethics Committee. Ethnic status of infants was recorded by the interviewers usin g defined criteria.29 The NESB infants were defined as those whose mothers speak a language other than English at home (excluded non-English speaking Indigenous mothers). Indigenous infants were recorded as those whose biological mother or biological father identified their infants as being of Aboriginal or Torres Strait Islander origin. Perceived unmet needs and related barriers to health service access The degree of parents’ perceived unmet needs for health services was measured at three recognised service levels: 1) primary health care (maternal and child health centre/phone help, maternal and child health nurse visits, general practitioner (GP), hospital outpatient clinic, and other medical or dental services); 2) secondary health care (hospitalisation and hospital emergency wards); and 3) tertiary health care (paediatrician and other specialist). The data of perceived unmet needs for services was collected by written questionnaires that asked parents “whether there have been any of these service(s) (as listed above) that this child has needed but could not obtain during the past 12 months”. The written questionnaire also asked for the details as to “why you could not get the service(s) that you needed for this child”, which included a list of possible barriers: “too expensive”, “too far away”, “transport problems”, “long waiting time for appointment”, “operating hours”, “own poor health”, “child care difficulties”, “culture or language reasons”, “services not available”, “family reasons” and “other reasons”. However, although “culture or language reasons” were listed as one of the possible reasons, it is not sufficient to provide accurate assessment whether the services offered were “culturally competent”. Data analyses Data was analysed according to survey statistical principles and took into account the design features of the LSAC study. Analyses were weighted for the multistage sampling design, allowing for AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2010 Public Health Association of Australia 31 Ou et al. Article unequal probabilities of selection into the sample, and for nonresponse. First-order Taylor linearization was used to obtain estimates of standard error taking into account the stratification and the correlation of responses within postcodes. Rao-Scott chi-square was used to examine the categorical variables. Survey logistic regression was conducted to examine the association between the risk groups of infants and the barriers to utilisation. The interaction effects between ethnic status and gender, as well as ethnic status and remoteness classification as defined by Australia Bureau of Statistics (ABS), were not significant for all multivariate models. Only main effects were included and presented in the final models. Statistical significance was calculated with 95% confidence intervals (CI). All analyses were performed using Stata SE10 (StataCorp. College Station,TX). Results Of the 4,151 infants included in the study, 52% were male, 14.6% were from NESB, and 4.1% were Indigenous (weighted percentage for survey data). The mean age of infants was 8.8 months (Standard Error (SE)=0.13). There were no age differences across the three groups. Overall, 96.9% of infants were rated by their carers as having good or excellent health status (Table 1). In total, 10% of Australian infants were reported as having at least one perceived unmet health care need. NESB (15.3%) and Indigenous infants (15.1%) had higher reported levels of perceived unmet needs than ESB infants (9.9%; p<0.001). Infants who had fair or poor health status, those from single parent families, children without siblings, or those who lived in remote areas reported higher levels of perceived unmet needs. The most frequent unmet needs were perceived for primary health care services: GPs, maternal and child health centres or phone help, and maternal and child health nurse visits (Table 2). The NESB infants had the highest levels of access difficulties in maternal and child health centres or phone help, maternal and child health nursing visits, hospital emergency department services and other medical or dental services; while Indigenous infants were reported having the greatest level of access difficulties for other specialists, and were more likely than ESB infants to have perceived unmet needs for hospital emergency services. Table 3 showed the barriers for perceived unmet needs encountered by Indigenous, NESB and ESB infants in access to health services. The number was slightly reduced within each group due to non-response to the barriers. For example, there were a total of 428 cases cited with perceived unmet needs. These cases included 328 ESB infants, 78 NESB infants and 22 Indigenous infants. The data for barriers was available in 397 cases as 30 cases were not cited with any barrier for perceived unmet needs, and one case was dropped during the weighting process. In general, the four most frequently reported barriers were “long waiting times for appointment” (43.1%), “services not available” (25.1%), “other reasons” (20.0%) and “too expensive to access” (19.2%). Indigenous infants were most likely to have barriers associated with cost, transport and family reasons. The NESB infants also 32 experienced these barriers to a greater extend than ESB infants. Moreover, NESB infants were the most likely to not access services because parents had child care difficulties, but were less likely to report that services were unavailable. The NESB and Indigenous infants were more likely than ESB infants to experience access barriers associated with cost, transport issues and family reasons (Table 4). After adjustment for the gender of infants, marital status of parents, parental education and employment status, as well as the number of siblings in the household, house ownership, family income, region of residence, remoteness area classification, and private health insurance coverage, the difference between NESB and ESB infants still remained for cost and child care difficulties, but not for transport problems and family reasons. While, the significant difference between Indigenous and ESB infants only remained for transport problem. Both unadjusted and adjusted models showed that ESB infants were more likely than NESB infants to not access services as they were “not available”. Only 172 cases (123 ESB, 41 NESB and eight Indigenous) and 246 cases (179 ESB, 54 NESB and 13 Indigenous) were included in the adjusted models for “own poor health” and “family reasons” respectively due to survey logistic regressions dropping the observations with missing values. Also, survey logistic regressions were not applicable for “culture or language barriers” among the three groups and “other reasons” for the Indigenous group because “culture and language barriers” were only cited by the NESB group, and there were no “other reasons” reported by the Indigenous group. Discussion This study is the first of its kind, at a national level, to examine ethnic and Indigenous disparity in perceived unmet needs and the related barriers to access in early childhood healthcare services in Australia. Our findings show that one in 10 Australian children were reported as being unable to access early childhood healthcare services at least once in the first 12 month period of their life. The NESB and Indigenous infants were reported as having more access difficulties than ESB infants with one in seven Indigenous mothers reporting access problems. Infants with fair or poor health status, families without house ownership, single parent families, families with only one child, and those living in a remote area were much more likely to suffer from the problems in accessing healthcare. These results suggest potential policy interventions and service delivery opportunities. Although uninsured children have been reported at highest risk for perceived unmet needs in the US,30 private insurance coverage was not associated with unmet health service needs in our study, reflecting that Australian public health insurance system may, to some extent, overcome the access difficulties for most uninsured children. Moreover, our study results concur with the large amount of existing literature in pointing to the disturbing fact that the Inverse Care Law (i.e. those who need more care still get less)31 is still very much in operation with dire consequences from the lack of intervention during the time when brain development is in its AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 2011 VOL. 35 NO. 1 Indigenous Health Ethnic and Indigenous access to early childhood healthcare most malleable period.31-34 This needed intervention should adopt a multidisplinary team or even trans-sectoral approach and be provided in a timely fashion within such critical period for brain stimulation and skills acquisition.10,11 The finding that infants from NESB and Indigenous groups experienced more perceived unmet needs in accessing health services concurs with research in the other culturally diverse countries, such as the US, the UK and Canada.2,35,36 Our results also revealed the diversity of perceived unmet needs in services reported by each of these three groups. For instance, NESB Table 1: Demography and frequencies of perceived unmet needs for health services.a Characteristics Infant male female Race/Ethnicity ESBb NESBc Indigenous Parent-rated health status good or excellent fair or poor Parental Marital status married single Education both Year 12 or equivalent single Year 12 or equivalent both under Year 12 Employment status both employed single employed both unemployed Family/Neighborhood Sibling in household none one two or more House ownership yes no Family income per week less than $499 $500-$999 $1,000-$1,499 $1,500-$1,999 $2,000 or more Region of residence metropolitan non-metropolitan Remoteness accessible moderate remote or very remote Private health insurance covered uncovered Total Participants N % Unmet needs % p-value 2,156 1,995 51.9 48.1 11.3 9.4 0.06 3,483 516 152 81.4 14.6 4.1 9.3 15.3 15.1 <0.001 4,021 129 96.9 3.1 10.1 19.7 <0.01 3,123 1,027 73.7 26.3 9.8 12.1 0.04 1,839 1,434 877 38.6 33.7 27.7 10.5 10.8 9.8 0.74 1,952 1,796 402 45.0 43.8 11.2 9.9 10.4 12.5 0.32 1,660 1,542 949 39.6 36.8 23.6 12.0 9.2 9.6 0.04 2,773 1,374 65.1 34.9 8.9 13.2 <0.001 444 1,276 1,107 586 548 12.5 32.8 27.2 14.3 13.3 13.4 10.0 9.5 11.2 9.2 0.19 2,603 1,548 66.7 33.3 10.0 11.1 0.33 3,257 664 177 81.5 14.8 3.7 10.4 8.6 19.6 <0.01 2,011 2,137 4,151 46.4 53.6 9.6 11.1 10.4 0.12 Notes: a) The number and percentages were weighted for the survey data. b) ESB=English speaking background. c) NESB=non-English speaking background. 2011 VOL. 35 NO. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 33 Ou et al. Article Table 2: Percentages of perceived unmet needs for health services in last 12 months by race/ethnicity.a Health services Maternal and child health centre/phone help Maternal and child health nurse visits General practitioner Paediatrician Other specialist Hospital emergency ward Hospital outpatient clinic Other medical or dental services Total n=4151 Infant groupsb ESBc (n=3483) NESBd (n=516) Indigenous (n=152) 1.7% 1.4% 2.8% 1.3% 0.8% 0.8% 0.2% 0.4% 1.3% 1.1% 2.7% 1.2% 0.7% 0.5% 0.2% 0.2% 4.4%e 3.2%f 2.7% 2.0% 0.5% 1.9%f 0.4% 1.5%f 0.9% 0.4% 4.5% 1.8% 2.9%f 1.8%e 0 0 Notes: a) The percentages were weighted for the survey data. b) ESB infants as a reference group. d) NESB=non-English speaking background. e) Significant at 5%. f) Significant at 1%. c) ESB=English speaking background. Table 3: The percentages of barriers among infants with perceived unmet needs for health services by ethnic groups.a Barriers Total (%) N=397 Infant groups (%) ESBb (n=306) NESBc (n=73) Indigenous (n=18) Too expensive to access Too far away Transport problems Long waiting time for appointment Operating hours Own poor health Child care difficulties Culture or language reasons Services not available Family reasons Other reasons 19.2 12.1 7.3 43.1 14.3 1.6 9.3 1.8 25.1 3.3 20.0 14.9 10.9 4.9 44.1 16.4 1.0 7.4 0.0 29.4 1.6 22.5 28.4d 13.8 12.9d 39.0 10.0 2.5 15.3d 8.2 10.4e 6.7d 16.6 40.3d 22.2 17.2d 45.5 3.5 6.1 10.6 0.0 27.0 13.3e 0.0d Notes: a) The percentages were weighted for the survey data. The total number was slightly reduced due to missing value to the barriers. b) ESB=English speaking background, ESB infants as a reference group. c) NESB=non-English speaking background. d) Significant at 5% e) Significant at 1%. ‘Family reasons’ in this study referred to any family issues preventing the access to care such as an argument with partner, the need to care for family members, or carrying out unexpected family duties. ‘Other reasons’ referred to any reasons that were not included in the listed barriers such as religious reasons or the personal preference for the services providers (e.g. female doctor, older doctor). Table 4: The survey logistic regression models (ORs and 95% CI) for related barriers in health services utilisation by ethnic group.a Barriers Crude ORs for barriers (n=397) NESB (n=73)b Indigenous (n=18) (ESB infants as reference groupc) Adjusted ORs for barriers (n=374)d NESB (n=67) Indigenous (n=18) (ESB infants as reference group) Too expensive to access Too far away Transport problems Long waiting time for appointment Operating hours Own poor healthe Child care difficulties Culture or language reasons Services not available Family reasonsf Other reasons 2.27 (1.19-4.32)g 1.31 (0.63-2.73) 2.86 (1.17-7.03)g 0.81 (0.44-1.50) 0.57 (0.24-1.34) 2.44 (0.39-15.45) 2.27 (1.05-4.90)g n/a 0.27 (0.12-0.59)h 4.51 (1.11-8.30)g 0.68 (0.36-1.29) 2.16 (1.05-4.45)g 2.29 (0.96-5.46) 3.05 (0.98-9.46) 0.85 (0.42-1.72) 0.58 (0.25-1.37) 2.59 (0.14-47.27) 2.90 (1.18-7.13)g n/a 0.29 (0.13-0.66)h 2.68 (0.58-12.44) 0.50 (0.24-1.05) 3.86 (1.27-11.75)g 2.33 (0.78-7.01) 4.02 (1.19-13.56)g 1.06 (0.41-2.72) 0.18 (0.02-1.36) 6.66 (0.62-71.85) 1.48 (0.30-7.29) n/a 0.86 (0.29-2.54) 9.62 (1.64-56.54)g n/a 2.68 (0.68-10.58) 1.80 (0.42-7.74) 5.15 (1.29-20.56)g 1.15 (0.39-3.39) 0.22 (0.03-1.77) 0.88 (0.04-19.80) 0.95 (0.14-6.25) n/a 0.57 (0.13-2.52) 5.00 (0.64-38.80) n/a Notes: a) The models were based on those infants (n=430) with unmet needs in health services utilisation. b) NESB=non-English speaking background. c) ESB=English speaking background. d) Adjusted by demographic variables: gender, parent marital status, education, employment status, number of siblings in household, home ownership, family income, region of residence, remoteness, and private health insurance coverage. e) Number varied for this variable in adjusted model due to missing (n=172). f) Number varied for this variable in adjusted model due to missing (n=246). g) Significant at 5%. h) Significant at 1%. Some of the confidence intervals were quite wide possibly due to the small sample sizes. 34 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 2011 VOL. 35 NO. 1 Indigenous Health Ethnic and Indigenous access to early childhood healthcare infants perceived more unmet need for maternal and child nurse visits, while Indigenous perceived more unmet need for specialist services. The level of perceived needs, to some extent, depends on both the perception of illness, injury, and awareness of health risk, and belief in the utility of intervention.37 The different levels of perceived unmet needs for health services between the three groups partly reflect different cultural beliefs, health literacy, expectations of service providers, diverse help-seeking behaviors and personal preferences.6,38 We showed, in our previous research, that Indigenous infants had much poorer health outcomes in comparison to their Englishspeaking counterparts, which led to plausible speculation that the higher the level of unmet needs in Indigenous infants may, in part, contribute to such health outcome disparity.18 Our study examined unmet need for child health services based on parents’ perceptions. Several factors could be considered as crucial for access process: parental knowledge, beliefs, and their attitudes concerning children’s symptoms, since an access action starts with perceived health need and decision to seek help.39 Other important potential contributors may include differential geographical distributions of ethnic and Indigenous infants and socioeconomic enabling factors. Despite these disparities of perceived unmet health care needs for the four types of health services: GPs, maternal and child health centres or phone help, maternal and child health nurse visits and paediatricians, these four types of services have been identified as the health care services most commonly used in the first 12 months of an infant life.18,40 This study suggests that the availability and accessibility of a range of mainstream health services were inequitable between Indigenous, NESB and ESB infants. Indigenous and NESB infants are at higher risk of not accessing health services, which were perceived by their parents as being required. The study also identifies the four most important barriers related to timely access to care. Almost half all carers cited long waiting times for appointment, one-quarter reported that services were not available; and one-fifth experienced cost barriers and other reasons. These findings confirm the previous findings that despite the positive impact of Medicare on equity of access to early childhood healthcare services, a number of systematic access barriers exist within children’s health services in Australia.41,42 The major barriers identified here relate to service provision (availability and accessibility), finance (cost or insurance covered), and other reasons, such as knowledge, literacy, communication, and health beliefs, that may be different between the three groups.43 Our study supports the previous findings that NESB and Indigenous infants were more likely than ESB infants to experience health service access difficulties.22,44 Indigenous parents cited cost as being the major reason for being unable to access care, at almost three times the rate of ESB parents. Problems with transport and family issues were also seen as relatively greater barriers. These findings were consistent with research in Australia’s Northern Territory reporting that Indigenous people from remote areas were more likely to cancel appointments due to inadequate transport to regional centres, lack of money for transport, 2011 VOL. 35 NO. 1 accommodation or food as well as having family problems in the use of health services.44 Living in remote areas also undoubtedly contributes to unmet needs reported in accessing specialist services by Indigenous groups. Remoteness was a crucial factor that led to the difficulties experienced by Indigenous groups in accessing health services.45 Almost one-third of all Indigenous mothers lived in remote, or very remote, areas between 2001 and 2004.25 In our study, the proportion of Indigenous infants living in remote areas may be underestimated due to the fact that 40% of children in remote areas were not included in the sample frame of the LSAC.28 However, it is also important to note that the majority of Indigenous infants did not live in remote, or very remote, areas and improving services in remote areas alone only solves small part of overall access and inequity issues. The significant barriers with Indigenous infants observed in the crude model were changed to non-significant after controlling for sex, health status, parental education and employment status, as well as the number of siblings in a household, house ownership, family income, private insurance coverage, region of residence, and remote area classification. It is worth noting that the guardians’ physical and mental status are critical factors in assuring that children are able to negotiate the health system and attend an appointment when needed. Despite lack of statistical significance between the groups in terms of stated barriers such as “own poor health” and “family reasons”, and given the small number of Indigenous carers included in the analysis, the results may be inclusive. Service providers still need to examine the appropriateness of their service before assuming the responsibilities of carers. The results may suggest that the higher level of barriers in accessing heath care for Indigenous infants can be explained by their greater need and poorer socioeconomic status. However, this was not the case for NESB infants. It may indicate that other factors such as health literacy, culture specific beliefs and behaviours, and English language proficiency may have a greater impact on the access to care apart from socioeconomic issues.6,38 Further research is needed to discover just how culture and ethnicity influence the utilisation of health services within the Australian context. We also found that service-operating hours were more frequently cited as a barrier by ESB mothers, at almost five times the rate reported by the Indigenous parents. The non-significance for this variable may be attributed to a very small sample size for the Indigenous group. The results may be explained by the higher levels of employment of ESB parents, which may mean greater difficulties in using health services that are only available during normal office operating hours. It may also reflect higher expectations of service availability by the ESB group as compared to the Indigenous group. Measures encouraging suitable workplace arrangements and flexible operating hours of heath services may facilitate full-time working parents gaining greater access to such services. Our study has several limitations. Retrospectively asking parents about perceived unmet needs and barriers may subject the AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 35 Ou et al. Article findings to recall bias. Newacheck and colleagues discussed the steps for parents to recognise and report unmet healthcare needs concerning their children. These steps included 1) recognition of occurred problem; 2) effort or consideration to meet the needs; 3) recall the situation, for example, health care was needed but not received during the past year; 4) willingness to report that unmet needs immediately after recall.1 They pointed out that reporting errors may be introduced by each of these steps, and perceived unmet needs would be possibly under-reported. However, it was not well documented in the literature whether over-reporting might also be a problem in some settings. Furthermore, the barriers reported were general ones and not linked to specific types of health services. This prevented us from understanding specific barriers for each individual service. Thirdly, the measure of health care needs is a complex interplay of perception, cultural and health belief, health service knowledge and literacy as well as health status. The perceived needs reported in this study may well not reflect a comparable level of healthcare needed between these groups. However, given the large scale national representative cohort data, our study was able to examine disparities of perceived unmet needs and associated barriers in access to health services among ethnic and Indigenous Australian infants. In particular, the perceived unmet needs for health services measured in the study were comprehensive, including primary, secondary and tertiary levels of health services. Moreover, the study surveyed a large array of possible barriers and provided the first national comparison of its kind between ESB, NESB and Indigenous infants. These results may facilitate policy-making in relation to health intervention and resource distribution as well as providing a benchmark to track the effectiveness of the interventions. Conclusion Parents’ perceived unmet needs existed in a number of health services for all Australian infants, but the levels of perceived unmet needs were different. Among the three infant groups, Indigenous and NESB infants are at higher risk of not accessing appropriate healthcare services. The most commonly cited barriers to parents, related to cost or insurance, availability and accessibility of service provision and other socioeconomic issues. While the higher incidence of barriers in Indigenous infants, compared to ESB infants, can be mostly explained by the higher needs and poorer socioeconomic status, and there may be culture specific and linguistic factors attributable to higher barriers in NESB infants. Parents’ health literacy, culture specific beliefs and behaviours, and English language proficiency may be considered as other crucial factors in affecting the access for children to health services. Implications Policy attention and operational changes are required to improve equity in accessing early childhood services, as well as to improve the overall access to healthcare services for all Australian infants. 36 Further research is needed to understand the specific causes of these unmet needs and related barriers. Acknowledgement This paper uses unit record data from Growing Up in Australia, the Longitudinal Study of Australian Children. The study is conducted in partnership between the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA), the Australian Institute of Family Studies (AIFS) and the Australian Bureau of Statistics (ABS). The findings and views reported in this paper are those of the author and should not be attributed to FaHCSIA, AIFS or the ABS. References 1. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics. 2000;105(4):989-97. 2. Ngui EM, Flores G. Unmet needs for specialty, dental, mental, and allied health care among children with special health care needs: Are there racial/ethnic disparities? J Health Care Poor Underserved. 2007;18(4):931-49. 3. Whitehead M. The concepts and principles of equity and health. Int J Qual Health Care. 1992;22(3):429-45. 4. Phillips KA, Mayer ML, Aday LA. Barriers to care among racial/ethnic groups under managed care. Health Aff (Millwood). 2000;19(4):65-75. 5. Bissar AR, Oikonomou C, Koch MJ, Schulte AG. Dental health, received care, and treatment needs in 11- to 13-year-old children with immigrant background in Heidelberg, Germany. Int J Paediatr Dent. 2007;17(5):364-70. 6. Gannotti ME, Kaplan LC, Handwerker WP, Groce NE. Cultural influences on health care use: Differences in perceived unmet needs and expectations of providers by Latino and Euro-American parents of children with special health care needs. J Dev Behav Pediatr. 2004;25(3):156-65. 7. Goodman A, Patel V, Leon DA. Child mental health differences amongst ethnic groups in Britain: A systematic review. BMC Public Health. 2008;8:258. 8. Newacheck PW, Hung YY, Wright KK. Racial and ethnic disparities in access to care for children with special health care needs. Ambulatory Pediatrics. 2002;2(4):247-54. 9. Szilagyi PG, Schor EL. The health of children. Health Serv Res. 1998;33(4):1101-39. 10. Heckman JJ. Invest in the Very Young. Chicago (ILL): Ounce of Prevention Fund and the University of Chicago Harri School of Public Policy Studies; 2000. 11. Wadsworth MEJ. Health inequalities in the life course perspective. Soc Sci Med. 1997;44(6):859-69. 12. The Marmot Review Team. Fair Society, Healthy Lives – Strategic Review of Health Inequalities in England Post 2010 [report on the Internet]. London (UK): Department for Epidemiology & Public Health, University College London; 2010 [cited 2010 May 6]. Available from: http://www.marmotreview.org/ 13. Chung PJ, Lee TC, Morrison JL, Schuster MA. Preventive care for children in the United States: Quality and barriers. Annu Rev Public Health. 2006;27:491-515. 14. Kataoka-Yahiro MR, Munet-Vilaro F. Barriers to preventive health care for young children. J Am Acad Nurse Pract. 2002;14(2):66-72. 15. Riportella-Muller R, Selby-Harrington ML, Richardson LA, Donat PLN, Luchok KJ, Quade D. Barriers to the use of preventive health care services for children. Public Health Rep. 1996;111(1):71-77. 16. Sobo EJ, Seid M, Reyes Gelhard L. Parent-identified barriers to pediatric health care: a process-oriented model. Health Serv Res. 2006;41(1):148-72. 17. Smedley A, Sith A, Nelson B. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): The National Academic Press; 2003. 18. Ou L, Chen J, Hillman K, Eastwood J. The comparison of health status and health services utilisation between Indigenous and non-Indigenous infants in Australia. Aust N Z J Public Health. 2010;34(1):50-6. 19. Ou L, Chen J, Hillman K. Health services utilisation disparities between English speaking and non-English speaking background Australian infants. BMC Public Health. 2010;10:182. 20. Efron D, Sewell JR, Horn M, Jewell F. Children in homeless families in Melbourne: Health status and use of health services. Med J Aust.1996;165 (11-12):630-33. 21. O’Callaghan AM, McAllister L, Wilson L. Barriers to accessing rural paediatric speech pathology services: Health care consumers’ perspectives. Aust J Rural Health. 2005;13(3):162-71. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 2011 VOL. 35 NO. 1 Indigenous Health Ethnic and Indigenous access to early childhood healthcare 22. Sheikh-Mohammed M, MacIntyre CR, Wood NJ, Leask J, Isaacs D. Barriers to access to health care for newly resettled sub-Saharan refugees in Australia. Med J Aust. 2006;185(11-12):594-97. 23. Taylor J. Access to health care for children in low-income families. Australian Journal of Public Health. 1994;18(1):111-13. 24. Australian Health Ministers’ Advisory Council. Aboriginal and Torres Strait Islander Health Performance Framework Report 2006. Canberra (AUST): Commonwealth Department of Health and Ageing; 2006. 25. Leeds KL, Gourley M, Laws PJ, Zhang J, AI-Yaman F, A SE. Indigenous Mothers and Their Babies, Australia 2001-2004. Canberra (AUST): Australian Institute of Health and Welfare; 2007. 26. Sanson A, Nicholson J, Ungerer J, Zubrick S, et al. Introducing the Longitudinal Study of Australian Children [discussion paper on the Internet]. LSAC Discussion Paper No.: 1. Melbourne (AUST): Australian Institute of Family Studies; 2002 [cited 2009 Aug 17]. Available from: http://www.aifs.gov.au/ growingup/pubs/discussion.html 27. Nicholson JM, Sanson A. A new longitudinal study of the health and wellbeing of Australian children: How will it help? Med J Aust. 2003;178(6):282-4. 28. Soloff C, Lawrence D, Jognstone R. Sample Design [technical paper on the Internet]. LSAC Technical Paper No.: 1. Melbourne (AUST): Australia Institute of Family Studies; 2005 [cited 2009 Aug 17]. Available from: http://www.aifs. gov.au/growingup/pubs/technical.html 29. Project Operations team. The Longitudinal Study of Australia Children: Data User Guide [study on the Internet]. Melbourne (AUST): Australia Institute of Family Studies; 2007 [cited 2009 Aug 17]. Available from: http://www.aifs. gov.au/growingup/data.html 30. DeVoe JE, Tillotson CJ, Wallace LS. Children’s receipt of health care services and family health insurance patterns. Ann Fam Med. 2009;7(5):406-13. 31. Hart JT. The inverse care law. Lancet. 1971;1(7696):405-12. 32. Zinkin PM, Cox CA. Child health clinics and inverse care laws: evidence from longitudinal study of 1878 pre school children. BMJ. 1976;2(6032):411-13. 33. Webb E. Children and the inverse care law. BMJ. 1998;316(7144):1588-91. 2011 VOL. 35 NO. 1 34. Brown S, Lumley J. Antenatal care: A case of the inverse care law? Australian Journal of Public Health. 1993;17(2):95-103. 35. Forrest CB, Riley AW, Vivier PM, Gordon NP, Starfield B. Predictors of children’s healthcare use: The value of child versus parental perspectives on healthcare needs. Med Care. 2004;42(3):232-8. 36. Macdonald E, Mohay H, Sorensen D, Alcorn N, McDermott B, Lee E, et al. Current delivery of infant mental health services: Are infant mental health needs being met? Australas Psychiatry. 2005;13(4):393-8. 37. Shengelia B, Tandon A, Adams OB, Murray CJL. Access, utilization, quality, and effective coverage: An integrated conceptual framework and measurement strategy. Soc Sci Med. 2005;61(1):97-109. 38. Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J. Culturally competent healthcare systems: A systematic review. Am J Prev Med. 2003;24 Suppl 3:68-79. 39. Anderson JG, Bartkus DE. Choice of medical care: A behavioral model of health and illness behavior. J Health Soc Behav. 1973;14(4):348-62. 40. Goldfeld SR, Wright M, Oberklaid F. Parents, infants and health care: Utilization of health services in the first 12 months of life. J Paediatr Child Health. 2003;39(4):249-53. 41. Kang M, Bernard D, Booth M, Quine S, Alperstein G, Usherwood T, et al. Access to primary health care for Australian young people: Service provider perspectives. Br J Gen Pract. 2003;53(497):947-52. 42. Mansour ME, Lanphear BP, DeWitt TG. Barriers to Asthma Care in Urban Children: Parent Perspectives. Pediatrics. 2000;106(3):512-19. 43. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: Addressing socioeconomic, racial and ethnic disparities in health care. JAMA. 2000;283(19):2579-84. 44. Gruen RL, Weeramanthri TS, Bailie RS. Outreach and improved access to specialist services for indigenous people in remote Australia: the requirements for sustainability. J Epidemiol Community Health. 2002;56(7):517-21. 45. Gruen RL, Bailie RS, D’Abbs PH, O’Rourke IC, O’Brien MM, Verma N. Improving access to specialist care for remote Aboriginal communities: Evaluation of a specialist outreach service. Med J Aust. 2001;174(10):507-11. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH © 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia 37