PEDIATRICS Vol. 121 No. 6 June 2008, pp. e1703-e1714 (doi:10.1542/peds.2007-2906)
ARTICLE |
The Language Spoken at Home and Disparities in Medical and Dental Health, Access to Care, and Use of Services in US Children
a Division of General Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
b Children's Medical Center, Dallas, Texas
c Signature Science, LLC, Austin, Texas
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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BACKGROUND AND OBJECTIVE. Fifty-five million Americans speak a non-English primary language at home, but little is known about health disparities for children in non-English-primary-language households. Our study objective was to examine whether disparities in medical and dental health, access to care, and use of services exist for children in non-English-primary-language households.
METHODS. The National Survey of Childhood Health was a telephone survey in 2003–2004 of a nationwide sample of parents of 102 353 children 0 to 17 years old. Disparities in medical and oral health and health care were examined for children in a non-English-primary-language household compared with children in English- primary-language households, both in bivariate analyses and in multivariable analyses that adjusted for 8 covariates (child's age, race/ethnicity, and medical or dental insurance coverage, caregiver's highest educational attainment and employment status, number of children and adults in the household, and poverty status).
RESULTS. Children in non-English-primary-language households were significantly more likely than children in English-primary-language households to be poor (42% vs 13%) and Latino or Asian/Pacific Islander. Significantly higher proportions of children in non-English-primary-language households were not in excellent/very good health (43% vs 12%), were overweight/at risk for overweight (48% vs 39%), had teeth in fair/poor condition (27% vs 7%), and were uninsured (27% vs 6%), sporadically insured (20% vs 10%), and lacked dental insurance (39% vs 20%). Children in non-English-primary-language households more often had no usual source of medical care (38% vs 13%), made no medical (27% vs 12%) or preventive dental (14% vs 6%) visits in the previous year, and had problems obtaining specialty care (40% vs 23%). Latino and Asian children in non-English-primary-language households had several unique disparities compared with white children in non-English-primary-language households. Almost all disparities persisted in multivariable analyses.
CONCLUSIONS. Compared with children in English-primary-language households, children in non-English-primary-language households experienced multiple disparities in medical and oral health, access to care, and use of services.
Key Words: disparities • language • communication barriers • children • Hispanics • Asians/Pacific Islanders • minorities
Abbreviations: NEPL—non-English primary language spoken at home • NSCH—National Survey of Children's Health • MCHB—Maternal and Child Health Bureau • CI—confidence interval • EPL—English primary language spoken at home • API—Asian/Pacific Islander • OR—odds ratio • OARO—overweight/at risk for overweight • USC—usual source of care • ED—emergency department • ADHD—attention-deficit/hyperactivity disorder • LEP—limited English proficiency
Approximately 55 million Americans speak a language other than English at home, equivalent to 
1 in 5 people in the United States.1 Spanish is by far the most common language other than English spoken at home, accounting for 62% of Americans who speak a non-English primary language at home (NEPL), followed by other Indo-European languages (19%), Asian and Pacific Islander languages (15%), and other languages (4%).1 Approximately 20% of those who speak a language other than English at home (10.9 million) are children.2 Comprehensive analyses of national data, however, have not been available to determine if health disparities exist for NEPL children. The aim of this study, therefore, was to examine whether disparities in medical and dental health, access to care, and use of services exist for NEPL children.
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METHODS |
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Data Source
With funding and direction from the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration, the National Center for Health Statistics of the Centers for Disease Control and Prevention conducted the National Survey of Children's Health (NSCH). Extensive details on NSCH methodology are provided elsewhere3; methods relevant to this analysis are briefly summarized.
NSCH Survey Instrument Derivation, Validation, and Domains
The NSCH produces national prevalence estimates for a variety of children's health indicators.3 A national expert panel consisting of state and federal MCHB program directors, representatives of family organizations, child health services researchers, and survey-design experts met to recommend the content domains for the survey. The 8 recommended domains, selected for their epidemiologic and policy importance, included sociodemographics, physical and mental health status, health insurance, health care utilization and access to health care, medical home, family functioning, parents' health, and neighborhood characteristics. In addition, age-specific modules were recommended to capture the developmentally appropriate aspects of child health and well-being. A subset of the national expert panel was chosen for a technical expert panel, which guided the development and testing of specific questionnaire items. When possible, questions from existing surveys were used for the NSCH to permit comparisons with those surveys and reduce the need for extensive pretesting. Questionnaire items recommended for inclusion by the technical expert panel were assessed through reviews by outside experts and selected members of the community of potential data users. Comments were also solicited from state MCHB agencies. MCHB management made the final decisions regarding the content of the survey.
The NSCH included 11 domains. The analysis herein focused on 48 measures of medical and dental health, access to care, and use of services; these measures were primarily contained in 6 NSCH domains: age eligibility and demographic screening characteristics; health and functional status; health insurance coverage; health care access and utilization; medical home; and additional demographic characteristics. All measures were based on assessments by the child's primary caretaker (parent or legal guardian) using validated interview questions; more objective measures, such as laboratory data or assessments by health care providers, were not part of the NSCH protocol.
Two NSCH pretests were fielded.3 The first pretest assessed respondent comprehension of interview questions and provided an estimate of questionnaire length. The second pretest incorporated questionnaire revisions based on the first pretest and was designed to ensure that all systems were functioning properly before beginning the study.
Sampling Procedures and Response Rate
Random-digit-dial sampling was conducted of households with children <18 years old from all 50 states and the District of Columbia, with 1 child randomly selected from each household as the survey subject. The survey respondent was the parent/guardian who knew most about the child's health care. The goal of the NSCH was to select representative samples of children <18 years old in each state. The target number of interviews was set at 2000 per state to permit reasonably precise estimates of the characteristics of children in each state. Sufficient precision was defined as a maximum relative standard error of 5% for point estimates of 20%. This same level of precision can alternatively be defined as a 95% confidence interval (CI) no wider than 5 percentage points for all point estimates.3
NSCH interviews were conducted in Spanish and English; the Spanish version of the NSCH was produced by a professional translator and then evaluated for accuracy and cultural appropriateness by a team of experienced Spanish interviewers and supervisors.3 The 6035 Spanish interviews comprised 2.5% of all screened households and 5.9% of all NSCH interviews. Of the 7912 children living in households with an NEPL, 83.3% (n = 6591) lived in Spanish-language households. If a contacted household was not able to respond in Spanish or English, it was excluded from the NSCH, because neither translated questionnaires nor trained interviewers proficient in languages other than English or Spanish were available. Thus, households designated as using an NEPL needed to have an English- or Spanish-speaking member available to be interviewed. Therefore, it was possible to include households in which neither English nor Spanish was the primary language spoken at home but the interviewee had sufficient English or Spanish proficiency to conduct the interview. NSCH data are not available on the specific non-English language spoken at home (because these data were not collected) or whether response rates differed according to the primary language spoken at home. The NSCH did not collect data on the immigration status of the interviewee or the index child; no additional information is available in NSCH documentation on the reason for this decision.
There were 102 353 NSCH interviews completed in 2003–2004. The screener-completion rate, which only measures the proportion of known households in which a resident reported whether any child lived in the household, was 87.8%. The interview-completion rate, a measure of the proportion of completed NSCH interviews among known households with children, was 68.8%. The resolution rate, indicating the proportion of telephone numbers that could be positively identified as residential or nonresidential, was 91.6%. The overall response rate (the product of these 3 rates) was 55.3%, which is comparable with the overall response rates of recent national surveys of children's health, including the National Survey of Children With Special Health Care Needs (overall response rate: 61.0%)4 and the National Survey of Early Childhood Health (overall response rate: 65.6%).5 Estimates based on sampling weights generalize to the noninstitutionalized population of children nationwide.3 Sampling weights also adjust for households with multiple telephone lines and for nonresponse bias, including for households without telephones, with multiple children, and with unknown household status/eligibility. All data presented herein are weighted estimates using NSCH sampling weights.
Analysis
In the NSCH, the interviewee was asked, "What is the primary language spoken in your home?" Response choices included: English, Spanish, any other language, don't know, or refused. The primary-language-spoken-at-home variable was dichotomized as English or non-English. The NEPL spoken at home could be any language other than English. NSCH data were unavailable on the specific non-English language spoken at home. Outcomes included 23 measures of medical and oral health status, 14 measures of access to medical and dental care, and 11 measures of use of medical and dental services. Parental ratings of child health status customarily are considered to be an acceptable proxy for child health status and have been shown to be significantly associated with utilization of a broad array of pediatric health services,6 and high agreement has been documented between parental reports of child health events and true occurrences.7 Bonferroni adjustments were not made, consistent with published guidelines,8 because a specific a priori hypothesis was tested (that NEPL children and those who speak an English primary language at home [EPL] significantly differ in medical and dental health, access to care, and use of services, after adjustment for relevant covariates) for each dependent variable rather than testing a universal null hypothesis or conducting an analysis without any a priori hypothesis. The child's BMI was calculated on the basis of the child's weight and height as reported by the parent or legal guardian; overweight was defined as a BMI of 
95th percentile for the child's age and gender, at risk for overweight was defined as a BMI at the 85th to 94th percentile for the child's age and gender, and underweight was defined as a BMI of 
5th percentile for the child's age and gender. Sporadic insurance was defined as having but then losing health insurance at any time during the previous 12 months. Although 1 NSCH question addressed interpreter availability, only bivariate analyses could be performed for this outcome because of limited sample sizes.
We examined the association of NEPL with sociodemographic characteristics and with outcomes. Among NEPL children, we examined the association of children's race/ethnicity (according to parental report) with sociodemographic characteristics and outcomes on the basis of our a priori hypothesis that significant intergroup differences would exist. The only racial groups with sufficient sample sizes for analyses were Latinos, whites, and Asians/Pacific Islanders (APIs). Because the sample sizes for many bivariate comparisons were large, giving them a high likelihood of being statistically significant, the reporting of specific bivariate findings includes qualifying terms to designate those statistically significant differences that are considered to be of clinical significance (ie, differences of approximately 5 percentage points) and those statistically significant differences that are considered to be clinically insignificant (ie, differing by only a few percentage points).
Multivariable analyses were conducted to adjust for relevant covariates (ie, factors that might confound the relationship between primary language spoken at home and the outcome variables, or race/ethnicity and the outcome variables among NEPL children). Covariates examined included the child's age, race/ethnicity, and medical or dental insurance coverage, caregivers' highest educational attainment and employment status, the number of children and adults in the household, and household income. All multivariable analyses were multiple logistic regressions performed by using forward stepwise procedures, with the initial 
-to-enter set at .15. The results of these multiple logistic regressions are expressed as odds ratios (ORs) with corresponding 95% CIs; as is customary, any adjusted OR is statistically significant when the 95% CI does not include 1.00. Only significant multivariable results are listed in the tables and summarized in the text.
Stata 89 was used for all analyses. Pearson's 
2 test statistic was used to test for independence between primary language categories or racial/ethnic groups and discrete factors. To account for the complex survey design, the statistic was turned into an F statistic with noninteger degrees of freedom by using a second-order Rao and Scott correction. The t statistic was used to compare the means of continuous factors, with degrees of freedom equal to the total number of primary sampling units minus the total number of strata.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Sociodemographic Characteristics
NEPL children were younger than EPL children (Table 1) and substantially more likely to be Latino or API. The parents of NEPL children were 10 times more likely to have not graduated high school. NEPL children lived in households with larger numbers of children and adults, but NEPL household members were less likely to have full-time employment. The parents of NEPL children were >10 times more likely to be foreign-born, but three quarters of the NEPL children were US-born. NEPL households were >3 times more likely than EPL households to be poor, and approximately two thirds of NEPL households were poor or near poor, compared with one third of the EPL households.
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Primary Language and Medical and Dental Health Status
NEPL children were substantially more likely to be in fair or poor health (Table 2). Overweight/at risk for overweight (OARO) occurred in almost half of the NEPL children but in just over one third of the EPL children. For 15 conditions, NEPL children had a significantly lower prevalence than EPL children (ie, NEPL children actually had a lower disease burden than EPL children). Fair/poor teeth condition occurred more often in NEPL children than EPL children (27% vs 7%).
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Primary Language and Access to Medical and Dental Care
NEPL children were substantially more likely than EPL children to have no health insurance (27% vs 6%) (Table 2). Approximately half of the NEPL children had public insurance (equivalent to 4 237 168 US children) compared with approximately one quarter of the EPL children, whereas only one quarter of the NEPL children were privately insured versus more than two thirds of EPL children. NEPL children who also were approximately twice as likely as EPL children to have had sporadic health insurance and no dental insurance. NEPL children were almost 3 times more likely to have had no usual source of care (USC), and parents of the NEPL children were more likely to report that their child's USC never/sometimes spent enough time with the child, explained things in an understandable way, and was able to provide needed telephone help or advice.
NEPL children were somewhat more likely to have not received all needed medical care (Table 2). Unmet medical care needs were more likely to be due to cost and uninsurance for NEPL children and due to health plan problems for EPL children. Problems obtaining specialty care were reported for 40% of the NEPL children versus 22% of EPL children, and problems obtaining special therapy were reported for 42% of the NEPL children and 28% of EPL children. NEPL children were more than twice as likely to have unmet dental care needs and significantly more likely to cite health plan problems and not knowing where to go for treatment as reasons for unmet dental care needs. NEPL children also had a slightly greater unmet prescription medication need.
Primary Language and Use of Medical and Dental Services
NEPL children were more likely in the previous year to have made no medical visit, no preventive care medical visit, and no preventive care medical visit with the USC, and to have made no preventive care medical visit with the USC in the previous 2 years (Table 2). In contrast, EPL children were more likely to have made emergency department (ED) visits, received mental health care, and used prescription medication in the previous year and to have needed/used prescription medication at the time of the survey. The NEPL children were more likely to have never seen a dentist, to have gone more than 1 year since the last dental visit, and to have had no routine preventive dental visit in the previous year.
Race/Ethnicity, NEPL, and Medical and Dental Health Status
Latino NEPL children were more likely to be in fair/poor health and to have teeth in fair/poor condition (Table 3). Latino NEPL children also were more likely to be OARO (50%) and to have learning disabilities, behavior problems, or emotional, developmental, or behavioral problems that needed treatment or counseling. API NEPL children were less likely to have hearing/vision problems, and white NEPL children had a higher prevalence of attention-deficit/hyperactivity disorder (ADHD). No racial/ethnic disparities were noted for other conditions.
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Race/Ethnicity, NEPL, and Access to Medical and Dental Care
Latino NEPL children had the highest rates of uninsurance and public insurance coverage (Table 3), whereas most API and white NEPL children were privately insured, and there were no differences in sporadic insurance. A high prevalence of lacking dental insurance occurred in all groups, but Latino NEPL children had the highest rate at 41%. Latino children were substantially more likely to have lacked a USC, and parents of Latino and API children more often reported that the USC does not spend enough time with their child. The only other significant difference in access was problems obtaining specialty care, which affected approximately two thirds of the API children, half of the white children, and one third of the Latino children.
Race/Ethnicity, NEPL, and Use of Medical and Dental Services
Although there was a nonsignificant overall 2 value for having had no medical visit in the previous year, pairwise comparisons revealed that the API and Latino children had a significant higher risk than the white children (Table 3). Receipt of mental health care was higher among Latino and white children versus the API children. Dramatic differences were documented in the need for an interpreter to speak with the child's health care provider, with one quarter of the Latinos having required interpreters versus 6% of the white and 0.2% of the API children.
Multivariable Analyses
Compared with EPL children, NEPL children had significantly greater adjusted odds of the health status and teeth condition not being excellent/very good (Table 4). In contrast, NEPL children had significantly reduced odds for 15 health conditions.
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NEPL children had significantly reduced access to medical and dental care for multiple indicators (Table 4). Compared with EPL children, NEPL children had
3.5 times the odds of having had no medical insurance, double the odds of having had sporadic insurance, and twice the odds of having had no dental insurance. NEPL children had approximately twice the odds of having had no USC, and the USC never or only sometimes spent enough time with the child, explained things in understandable ways to parents, and provided needed telephone help or advice. The NEPL children had 5 times the odds of unmet medical care needs due to an inability to find a doctor that accepted the child's medical insurance, 10 times the odds of unmet medical care needs due to dissatisfaction with the child's doctor, and almost double the odds of a problem obtaining specialty care. NEPL children had approximately double the odds of EPL children of unmet dental care needs and more than triple the odds of unmet dental care needs due to the dentist not knowing how to treat or provide care. NEPL children had lower odds for only 1 access indicator: needing but not receiving a prescription. Compared with EPL children, NEPL children had significantly greater odds of having made no medical visit or preventive care medical visit in the previous year and no preventive care medical visit in the previous 2 years, having received no mental health care in the previous year, and going more than 1 year since the last dental visit (Table 4). In contrast, NEPL children were less likely to have made an ED visit in the previous year and to have needed/used prescription medications.
Among the NEPL children, certain significant differences were noted among racial/ethnic groups (Table 5). Compared with white children, Latino children had triple the odds of their health status not being excellent/very good, double the odds of being OARO and their teeth condition not being excellent/very good, and 14 times the odds of bone/joint/muscle problems but reduced odds of ADHD. Compared with white children, API children had reduced odds of needing/obtaining special therapy and having learning disabilities, hearing/vision problems, ADHD, developmental delay, and speech problems.
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Compared with white NEPL children, Latino NEPL children had significantly greater odds of having had no medical insurance, no USC, a USC that never/only sometimes spent enough time with the child, unmet dental care needs, having needed but not receiving prescription medications, and having needed interpreter services. API children were more likely than white children to have had a USC that never/only sometimes spent enough time with the child and explained things to parents in understandable ways, unmet dental care needs, no medical visit in the previous year, no preventive medical care visit in the previous year, no preventive medical care visit with the USC in the previous 1 or 2 years, and no mental health care in the previous year and having needed but not receiving prescription medications but lower odds of having needed interpreters.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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More than 10 million US children live in NEPL households.2 Study findings have revealed that three fourths of NEPL children are US-born, making most of them US citizens or eligible for citizenship. However, NEPL children are substantially more likely to live in poor or near-poor households, with more than two thirds being poor/near poor versus one third of EPL children. Low income is a known risk factor for adverse health outcomes in children,10 suggesting that clinicians who care for NEPL children should inquire about family income and ensure access to programs associated with improved outcomes for poor children, including Head Start,11 the Supplemental Nutrition Program for Women, Infants, and Children,12 and school nutrition programs.13
NEPL children are significantly more likely than EPL children to have suboptimal health and dental status but have lower odds of 15 health conditions. Reasons for this paradox are unclear. Because many of the 15 conditions require a health care provider's diagnosis, this paradox could reflect a relative underdiagnosis of specific conditions as a result of significantly reduced access to care for NEPL children. An analogous phenomenon has been reported for childhood asthma, in which racial/ethnic minority groups in the United Kingdom have been found to have a higher risk of both underdiagnosis and undertreatment.14 It also has been hypothesized that a higher risk of underdiagnosis of language disorders exists among bilingual children due to language evaluations not being conducted because of the belief that language tests for bilingual individuals are not available and due to misattributing language delays to normal bilingual development.15 Alternatively, lower rates for at least some specific conditions could be related to the "healthy immigrant effect," in which lower acculturation has been associated with better outcomes for several child health indicators.16 Additional studies clearly are needed on this intriguing paradox.
NEPL children have a significantly higher risk of impaired access to health and dental care, including greater odds of uninsurance, sporadic insurance, no dental insurance, no USC, problems getting specialty care, and unmet dental care needs. Providing all children with health and dental insurance could significantly reduce access barriers to health and dental care for children who speak an NEPL. Studies have documented that uninsured children experience improved health care access and outcomes after obtaining coverage under the State Children's Health Insurance Program (SCHIP).17,18 However, parents of uninsured NEPL children often were unable to insure their children because of a lack of knowledge about insurance programs, language barriers, immigration issues, hassles, misinformation from insurance representatives, and system problems.19 A randomized, controlled trial,20 however, demonstrated that community-based case managers are substantially more effective in insuring uninsured children than traditional Medicaid/SCHIP outreach and enrollment; most children in this study were from NEPL households, so community health workers may prove useful in eliminating insurance-coverage disparities for NEPL children.
Non–insurance-related barriers, however, seem to significantly hamper access to care for NEPL children even when those children have insurance coverage and a USC. NEPL children have significantly greater odds of unmet medical care needs because of dissatisfaction with physicians and because a physician cannot be found who accepts the child's insurance, and they have triple the odds of unmet dental care needs because of their dentist not knowing how to treat them or provide care. These findings are consistent with previous research that found that nonfinancial barriers play a major role in impaired access to care for Latino children, including language barriers, cultural issues, transportation problems, difficulty making appointments, and inconvenient clinic hours.21 Providing optimal access to care for NEPL children will require addressing these nonfinancial access barriers through such measures as improved access to medical interpreters, enhanced cultural competency, and redesign of health care systems so that they are more family centered and convenient.
NEPL children are significantly more likely to not receive essential health and dental care services, including yearly preventive care medical visits and dental visits. Almost 1 in 3 children who speak an NEPL (3 million) have not made a preventive medical visit in the previous year, and more than 1 in 3 children (3.8 million) have gone >1 year since their last dental visit. Higher risks of lacking medical and dental insurance and encountering nonfinancial barriers to care may account for the lower receipt of essential health and dental care by NEPL children. These findings suggest that special efforts, such as targeted education and outreach, may be needed to ensure that NEPL children receive regular preventive medical and dental care.
Certain noteworthy disparities in the quality of care were noted for NEPL children. Parents of NEPL children are significantly more likely than those of EPL children to report that their child's USC never or only sometimes spends enough time with the child, explains things in an understandable way, and is able to provide needed telephone help or advice and that their child had unmet dental care needs because of dentists not knowing how to treat them or provide care. Problems with the quality of care provided by the USC may at least in part be related to language barriers, which have been shown to result in a higher risk of impaired communication, lower patient satisfaction, adverse outcomes, and compromised patient safety.22–24 These disparities in quality, thus, might be reduced by enhancing access to trained professional medical interpreters and bilingual health care providers, which has been shown to be associated with optimal communication, the highest patient satisfaction, the best outcomes, and the fewest interpreter errors of potential clinical consequence.22,23 In contrast, it is unclear why NEPL children have a greater risk of unmet dental care needs due to dentists not knowing how to treat them or provide care; additional research is warranted on both the causes and remedies for this quality deficiency.
The primary language spoken at home in NEPL households in the US is predominantly Spanish (62%), followed by other Indo-European languages (19%) and API languages (15%).25 Compared with white NEPL children, Latino and API children have several unique disparities of note for clinicians and policy makers. Latino NEPL children have higher adjusted odds than white NEPL children of suboptimal health status and teeth condition, overweight, OARO, bone/joint/muscle problems, lack of medical insurance and a USC, and unmet dental and prescription needs. These findings suggest the need for careful screening of Latino NEPL children for these disparities during medical and dental visits. In addition, 1 in 4 Latino NEPL children and their families require medical interpretation, equivalent to more than triple the odds of white children needing interpretation, so it is especially important to screen for limited English proficiency (LEP) among Latino NEPL children and their families and to provide trained medical interpreters or bilingual providers to those with LEP. Compared with white NEPL children, API NEPL children have significantly reduced odds of several medical conditions but greater odds of impaired access to care, unmet need for prescriptions, and lower receipt of medical and mental health care services. The findings of reduced access and receipt of health services and needed prescriptions are consistent with those from recent research both on API children experiencing language barriers and disparities for API children in general.26,27
Certain study limitations should be noted. The NSCH examined only the primary language spoken at home and not LEP; research has documented that LEP is a more useful measure of language barriers than the primary language spoken at home in examining disparities in health and health care.28 Disparities identified in our study, therefore, may be of greater magnitude among children and families with LEP. Certain disparities could be caused by racial/ethnic, linguistic, or cultural differences among groups in recognizing or admitting unmet health care needs. The study findings (including children's weight and height) were based on self-report by the parent or legal guardian and, thus, could be subject to bias or might vary from health care provider reports or laboratory data (were such reports or data available). NSCH data were available for >8400 API children, distinguishing the NSCH as having the largest identified sample of API children of any child-specific nationally representative database to date. Nevertheless, the sample size was relatively small for the subsample of API children who spoke an NEPL (181), so it would be useful to confirm our study findings in larger primary data sets and increase the sample size of API children who speak an NEPL in future large national databases. Although we examined whether there was any medical visit or preventive medical visit in the previous 12 or 24 months for all children, we did not examine the proportion of each racial/ethnic group who met American Academy of Pediatrics recommendations for age-appropriate well-child care visits, which is a topic that should be examined in future analyses.
Data on the immigration status of the children and parents were not available in the NSCH; studies have shown that low-income children in immigrant families and those who are immigrants themselves have high risks of lacking insurance and having impaired access to care.29 On the other hand, a recent study28 revealed that having parents with LEP was significantly associated with higher adjusted odds of children being uninsured, having suboptimal health status, and experiencing impaired access to care even after adjustment for parental immigration status and other relevant covariates, but this was not the case for NEPL, so additional studies are warranted of the impact of NEPL, LEP, and parental and child immigration status on child health outcomes.
Another limitation was that the NSCH was administered only in English and Spanish, so NEPL households with primary caretakers who did not speak English or Spanish were excluded. NSCH data on NEPL households, therefore, may not completely generalize to NSCH households in the United States because of the exclusion of non–Spanish-speaking LEP households; thus, the findings may underestimate disparities for the API and other non-Latino children. The latest US Census data, however, indicated that the study findings should generalize to at least 85% of NEPL households, because only 15% of those in NEPL households both have LEP and speak a language other than Spanish at home.30 In addition, 83.3% of children in NEPL households in the NSCH spoke Spanish.2 Thus, estimates from the US Census30 (documenting that 60.8% of non–Spanish-language NEPL households are English-proficient) indicate that the NSCH data should generalize to 93.5% of NEPL households with children in the United States (83.3% [the proportion of Spanish-language NEPL households] plus 10.2% [the 60.8% of the remaining 16.7% of NEPL households with a language other than English or Spanish spoken at home but with an English-proficient parent or guardian]). A final NSCH limitation was that sample sizes were insufficient to examine the association of needing but not obtaining interpreters with health and dental outcomes.
Certain study strengths also should be noted. The NSCH represents the largest and most diverse national database to date that contains data on the primary language spoken at home. In addition, this is the first analysis, to our knowledge, that comprehensively examined the impact of NEPL on medical and dental health, access to care, and use of services in a nationally representative sample of US children.
Analysis of this large, nationally representative database revealed that, compared with EPL children, NEPL children experienced multiple disparities in medical and oral health, access to care, and use of services. A key first step in identifying, monitoring, and eliminating these disparities is the routine collection by health care institutions and systems of data on the primary language spoken at home and LEP for all patients. Recent surveys of US hospitals31,32 revealed that only 39% to 60% of hospitals routinely collect any kind of language data on patients, recording language information is highly variable across hospitals and rarely is a required data-collection field, and there is little consistency in the type of data collected, suggesting that disparities may persist for NEPL children until improvements are achieved in language data collection.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Compared with EPL children, NEPL children experience multiple disparities in medical and oral health, access to care, and use of services. NEPL children are substantially more likely to live in low-income households, suggesting that clinicians who care for NEPL children should inquire about family income and consider referrals to programs documented to benefit poor children, including Head Start, the Supplemental Nutrition Program for Women, Infants, and Children, and school nutrition programs. NEPL children are at significantly higher risk of impaired access to health and dental care, including preventive and specialty care, and ensuring that all NEPL children have health and dental insurance may substantially help reduce financial barriers to care but may require innovative outreach and enrollment interventions such as using community health workers. NEPL children also face several nonfinancial barriers to health and dental care access, and the elimination of such barriers may necessitate improved access to medical interpreters, better cultural competency training, and more family-centered health care systems. Compared with white NEPL children, Latino and API NEPL children have several unique disparities of note for clinicians and policy makers; Latino NEPL children have higher risks of suboptimal health status and teeth condition, overweight, lack of medical insurance and a USC, unmet dental and prescription needs, and the need for interpreters, and API NEPL children have higher risks of impaired access to care, unmet need for prescriptions, and lower receipt of medical and mental health care services. NEPL children experience disparities in the quality of medical and dental care, which, at least in part, may relate to language barriers, and therefore may be responsive to enhanced access to medical interpreters and bilingual health care providers.
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FOOTNOTES |
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Accepted Jan 2, 2008.
Address correspondence to Glenn Flores, MD, University of Texas Southwestern Medical Center, Division of General Pediatrics, Department of Pediatrics, 5323 Harry Hines Blvd, Dallas, TX 75390. E-mail: glenn.flores{at}utsouthwestern.edu
This work was presented in part at the annual meetings of the Pediatric Academic Societies, May 1, 2006, San Francisco, CA; AcademyHealth, June 26, 2006, Seattle, WA; and the American Public Health Association, November 6, 2006, Boston, MA.
The authors have indicated they have no financial relationships relevant to this article to disclose.
| What's Known on This Subject Fifty-five million Americans speak an NEPL, but little is known about health disparities for NEPL children.
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| What This Study Adds Compared with EPL children, NEPL children experience multiple disparities in medical and oral health, access to care, and use of services.
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REFERENCES |
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- US Census Bureau. Selected social characteristics in the United States: 2006. Available at: http://factfinder.census.gov/servlet/ADPTable?_bm=y&-qr_name=ACS_2006_EST_G00_DP2&-geo_id=01000US&-ds_name=ACS_2006_EST_G00_&-_lang=en&-redoLog=false&-_sse=on. Accessed December 14, 2007
- US Census Bureau. S1603: characteristics of people by language spoken at home. Available at: http://factfinder.census.gov/servlet/STTable?_bm=y&-geo_id=01000US&-qr_name=ACS_2006_EST_G00_S1603&-ds_name=ACS_2006_EST_G00_&-_lang=en&-redoLog=false&-format=&-CONTEXT=st. Accessed December 14, 2007
- Blumberg SJ, Olson L, Frankel MR, Osborn L, Srinath KP, Giambo P. Design and operation of the National Survey of Children's Health, 2003. Vital Health Stat 1. 2005;(43):1 –124
- Blumberg SJ, Olson L, Frankel M, et al. Design and operation of the National Survey of Children With Special Health Care Needs, 2001. Vital Health Stat 1. 2003;(41):1 –136
- Blumberg SJ, Olson L, Osborn L, Srinath KP, Harrison H. Design and operation of the National Survey of Early Childhood Health, 2000. Vital Health Stat 1. 2002;(40):1 –97
- Minkovitz CS, O'Campo PJ, Chen YH, Grason HA. Associations between maternal and child health status and patterns of medical care use. Ambul Pediatr. 2002;2 (2):85 –92[CrossRef][Web of Science][Medline]
- Pless CE, Pless IB. How well they remember: the accuracy of parental reports.
Arch Pediatr Adolesc Med. 1995;149
(5):553
–558
[Abstract/Free Full Text] - Perneger TV. What's wrong with Bonferroni adjustments.
BMJ. 1998;316
(7139):1236
–1238
[Free Full Text] - Stata Corp. Stata Survey Data Reference Manual. Release 8. College Station, TX; Stata Corp: 2003
- Wise PH, Meyers A. Poverty and child health. Pediatr Clin North Am. 1988;35 (6):1169 –1186[Web of Science][Medline]
- Barnett WS. Long-term cognitive and academic effects of early childhood education on children in poverty. Prev Med. 1998;27 (2):204 –207[CrossRef][Web of Science][Medline]
- Devaney BL, Ellwood MR, Love JM. Programs that mitigate the effects of poverty on children. Future Child. 1997;7 (2):88 –112[CrossRef][Web of Science][Medline]
- Meyers AF, Sampson AE, Weitzman M, Rogers BL, Kayne H. School Breakfast Program and school performance.
Am J Dis Child. 1989;143
(10):1234
–1239
[Abstract/Free Full Text] - Duran-Tauleria E, Rona RJ, Chinn S, Burney P. Influence of ethnic group on asthma treatment in children in 1990–1: national cross sectional study.
BMJ. 1996;313
(7050):148
–152
[Abstract/Free Full Text] - Toppelberg CO, Medrano L, Peña Morgens L, Nieto-Castañon A. Bilingual children referred for psychiatric services: associations of language disorders, language skills, and psychopathology. J Am Acad Child Adolesc Psychiatry. 2002;41 (6):712 –722[CrossRef][Medline]
- Flores G, Brotanek J. The healthy immigrant effect: a greater understanding might help us improve the health of all children.
Arch Pediatr Adolesc Med. 2005;159
(3):295
–297
[Free Full Text] - Szilagyi PG, Dick AW, Klein JD, Shone LP, Zwanziger J, McInerny T. Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP). Pediatrics. 2004;113 (5). Available at: www.pediatrics.org/cgi/content/full/113/5/e395
- Kempe A, Beaty BL, Crane LA, et al. Changes in access, utilization, and quality of care after enrollment into a state child health insurance plan.
Pediatrics. 2005;115
(2):364
–371
[Abstract/Free Full Text] - Flores G, Abreu M, Brown V, Tomany-Korman SC. How Medicaid and the State Children's Health Insurance Program can do a better job of insuring uninsured children: the perspectives of parents of uninsured Latino children. Ambul Pediatr. 2005;5 (6):332 –340[CrossRef][Web of Science][Medline]
- Flores G, Abreu M, Chaisson CE, et al. A randomized trial of the effectiveness of community-based case management in insuring uninsured Latino children.
Pediatrics. 2005;116
(6):1433
–1441
[Abstract/Free Full Text] - Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to health care for Latino children.
Arch Pediatr Adolesc Med. 1998;152
(11):1119
–1125
[Abstract/Free Full Text] - Flores G. The impact of medical interpreter services on the quality of health care: a systematic review.
Med Care Res Rev. 2005;62
(3):255
–299
[Abstract/Free Full Text] - Flores G. Language barriers to health care in the United States.
N Engl J Med. 2006;355
(3):229
–231
[Free Full Text] - Flores G. Language barrier. Available at: www.webmm.ahrq.gov/case.aspx?caseID=123. Accessed April 19, 2007
- US Census Bureau. Selected social characteristics in the United States: 2005. Available at: http://factfinder.census.gov/servlet/ADPTable?_bm=y&-geo_id=01000US&-qr_name=ACS_2005_EST_G00_DP2&-ds_name=&-_lang=en&-redoLog=false&-format=. Accessed April 18, 2007
- Yu SM, Huang ZJ, Singh GK. Health status and health services utilization among US Chinese, Asian Indian, Filipino, and other Asian/Pacific Islander Children.
Pediatrics. 2004;113
(1 pt 1):101
–107
[Abstract/Free Full Text] - Flores G, Tomany-Korman SC. Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008;121 (2). Available at: www.pediatrics.org/cgi/content/full/121/2/e286
- Flores G, Abreu M, Tomany-Korman SC. Limited English proficiency, primary language spoken at home, and disparities in children's health and healthcare: how language barriers are measured matters. Public Health Rep. 2005;120 (4):418 –430[Web of Science][Medline]
- Ku L. Improving health insurance and access to care for children in immigrant families. Ambul Pediatr. 2007;7 (6):412 –420[Web of Science][Medline]
- US Census Bureau. Selected social characteristics in the United States: 2005. Available at: http://factfinder.census.gov/servlet/ADPTable?_bm=y&-geo_id=01000US&-qr_name=ACS_2005_EST_G00_DP2&-ds_name=ACS_2005_EST_G00_&-_lang=en&-_caller=geoselect&-state=adp&-format=. Accessed August 8, 2007
- Hasnain-Wynia R, Pittman M, Pierce D. Who, When, and How: The Current State of Race, Ethnicity, and Primary Language Data Collection in Hospitals. New York, NY: Commonwealth Fund; 2004. Publication 726
- Regenstein M, Sickler D. Race, Ethnicity, and Language of Patients: Hospital Practices Regarding Collection of Information to Address Disparities in Health Care. Washington, DC: National Public Health and Hospital Institute; 2006
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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