Advertising Disclaimer »

Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

A statement of reaffirmation for this policy was published at

From the American Academy of PediatricsTechnical Report

Racial and Ethnic Disparities in the Health and Health Care of Children

Glenn Flores and THE COMMITTEE ON PEDIATRIC RESEARCH
Pediatrics April 2010, 125 (4) e979-e1020; DOI: https://doi.org/10.1542/peds.2010-0188
Download PDF

Abstract

OBJECTIVE: This technical report reviews and synthesizes the published literature on racial/ethnic disparities in children's health and health care.

METHODS: A systematic review of the literature was conducted for articles published between 1950 and March 2007. Inclusion criteria were peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Search terms used included “child,” “disparities,” and the Index Medicus terms for each racial/ethnic minority group.

RESULTS: Of 781 articles initially reviewed, 111 met inclusion criteria and constituted the final database. Review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Mortality-rate disparities were noted for children in all 4 major US racial/ethnic minority groups, including substantially greater risks than white children of all-cause mortality; death from drowning, from acute lymphoblastic leukemia, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Certain methodologic flaws were commonly observed among excluded studies, including failure to evaluate children separately from adults (22%), combining all nonwhite children into 1 group (9%), and failure to provide a white comparison group (8%). Among studies in the final database, 22% did not perform multivariable or stratified analyses to ensure that disparities persisted after adjustment for potential confounders.

CONCLUSIONS: Racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care. Methodologic flaws were identified in how such disparities are sometimes documented and analyzed. Optimal health and health care for all children will require recognition of disparities as pervasive problems, methodologically sound disparities studies, and rigorous evaluation of disparities interventions.

INTRODUCTION

Racial/ethnic disparities in health and health care recently have received considerable attention. The Agency for Healthcare Research and Quality has issued an annual national health care disparities report since 2003.1,2 Reduction and elimination of disparities is one of the major goals of Healthy People 2010,3 part of the strategic plan of the Eunice Kennedy Shriver National Institute of Child Health and Human Development,4 and part of the strategic imperatives of the Centers for Disease Control and Prevention (CDC).5 A separate National Institutes of Health center devoted to minority health and health disparities (the National Center for Minority Health and Health Disparities) was founded in 2000.6 The Institute of Medicine released a landmark monograph on disparities,7 and a federal bipartisan bill targeting health care disparities recently was introduced.8

Little attention has been paid, however, to racial/ethnic disparities in the health and health care of children. For example, only 5 of 103 studies in the Institute of Medicine's extensive review of the literature on health care disparities specifically addressed racial/ethnic disparities in children's health care.7 The purpose of this technical report, therefore, is to review and synthesize the published literature on racial/ethnic disparities in children's health and health care. The report begins with definitions of key terms and an overview of sociodemographic trends in minority children. Specific minority groups, the importance of racial/ethnic subgroups, studies of interventions to reduce racial/ethnic disparities, and methodologic issues are then reviewed.

DEFINITIONS

“Race/ethnicity” is defined as the child's racial or ethnic group (including “multiracial”), as designated by the parent and/or child. “Minority” will be the term used for children of nonwhite race/ethnicity. Although multiple definitions have been proposed for the term “disparities,” the Health Resources and Services Administration definition of disparities was used, which defines disparities as “population-specific differences in the presence of disease, health outcomes, or access to care.”9

METHODS

Only statistically significant disparities are reported herein (ie, those with either a P value of less than .05 or 95% confidence intervals [CIs] that are nonoverlapping with non-Latino white children). The only exception to this rule was inclusion of certain crude outcome rates in large population-based samples in which the differences were considered quantitatively or clinically significant (ie, when there was at least a 50% difference in rates between a specific racial/ethnic minority group and the white population). Only studies that examined racial/ethnic disparities in the context of comparisons to white children were included in the literature review. Notation was made of whether disparities included adjustment for relevant covariates. When appropriate data were available, secular trends for specific disparities are described. Unless otherwise noted, the reference group for any racial/ethnic disparity is non-Latino white children.

LITERATURE SEARCH

The scope of published literature on racial/ethnic disparities is broad. In addition, although racial/ethnic disparities in neonatal and infant mortality rates10 and dental care11 have been fairly well described, relatively little has been published on racial/ethnic disparities in children and adolescents. The terms that have been used to describe disparities also have been neither standardized nor consistent. As a consequence, the literature search was limited to only those studies that specifically examined racial/ethnic disparities for US children and adolescents, to ensure a focus on disparities and a body of literature in urgent need of a systematic review. Thus, articles on racial/ethnic disparities in neonatal and infant mortality and dental care were excluded, because disparities in these domains have comparatively been more well described, and articles on pediatric workforce diversity, an area that was addressed in a recent American Academy of Pediatrics (AAP) policy statement,12 also were excluded.

The database used for the literature search was Ovid Medline; the search encompassed the years 1950 through the first week of March 2007. The initial search strategy included the terms “child” and “disparities” (both as medical subject heading terms and key words), which yielded 666 citations. To ensure that no relevant citations were missed, individual searches also were performed by using “disparities,” “child,” and Index Medicus terms for each racial/ethnic minority group, which yielded the following children's disparities references: “African continental ancestry group,” n = 35; “Asian continental ancestry group,” n = 5; “Pacific Islanders,” n = 2; “Indians, North American,” n = 17; “multiracial,” n = 1; and “Hispanic Americans,” n = 55. The initial total of all citations was, therefore, 781 articles. To ensure the consistency and reproducibility of this literature search, additional secondary references were not included from the citation lists of the primary articles included in the database.

Abstracts for all 781 articles were reviewed. Because the focus of the literature review was original, peer-reviewed articles in English on racial/ethnic disparities in the health and health care of US children, review articles, editorials, commentaries, perspective pieces, theoretical or conceptual pieces, transcripts of speeches, letters to the editor, dental care articles, articles that addressed adults or the elderly, articles without analysis of racial/ethnic disparities, articles on neonatal or infant mortality issues, articles on workforce diversity, articles that did not examine disparities in the health of US children, and duplicate citations were excluded. Application of these exclusion criteria yielded 227 articles. The full print versions of these remaining 227 articles were reviewed, and reapplication of the exclusion criteria yielded a final database of 111 articles, 2 of which examined interventions aimed at reducing racial/ethnic disparities (and were considered separately).

SOCIODEMOGRAPHICS OF MINORITY CHILDREN IN THE UNITED STATES

The United States is experiencing a demographic surge in minority children (Fig 1). There are 31.4 million children (younger than 18 years old) of nonwhite race/ethnicity in the United States,13 comprising 43% of children, and representing an 11% increase since 200014 and a 58% increase since 1990.15 Since 2000, minorities have represented more than half of the population of the nation's 100 largest cities, and 42 of the 100 largest US cities are “minority majority” (defined as populations in which racial/ethnic minorities outnumber the white population).16 In California, the largest state in the nation, minorities have outnumbered whites since 2000, and currently represent 57% of the state's population.17,18 Conservative estimates indicate that minorities will constitute half of US children by 2040.19

FIGURE 1
FIGURE 1

Growth of racial/ethnic minority population of US children between 1990 and 2006. ACS indicates American Community Survey. Data were unavailable for APIs for the 1990 US Census, so data depicted are from the 2000 US Census.

Latinos are the largest and fastest-growing minority group of US children (Fig 1), representing 20% of children in America (equivalent to 15 million).13,20 African Americans (AAs) are the second-largest minority group of US children, representing 15% of children in America (equivalent to 10.9 million)13; between 1990 and 2006, their population proportion slightly decreased. Asians/Pacific Islanders (APIs) are the third-largest minority group of US children, representing 4% of children in America (equivalent to 3 million)13; between 2000 and 2006, their population proportion grew by 14% (1990 US Census data are not available on API children). American Indians/Alaska Natives (AIs/ANs) represent 1% of children in America (equivalent to ∼661 000)13; between 1990 and 2006, their population proportion decreased by 18%. The number of multiracial children in the United States (ie, self-designated by the caregiver as belonging to 2 or more races) in 2006 was 2.9 million, representing 4% of the US population of children,13 a proportion that has not changed since 1990.

HEALTH AND HEALTH CARE DISPARITIES IN SPECIFIC RACIAL/ETHNIC GROUPS OF CHILDREN

African Americans

The vast majority of articles (94 of 109 [86%]) addressed disparities in AA children (Table 1).

View this table:
TABLE 1

Disparities in the Health and Health Care of AA Children

Mortality

Eight articles documented AA/white disparities in mortality rates. Overall childhood mortality rates were found to be consistently higher for AA children; national data for a 43-year period revealed marked crude mortality-rate disparities in young children 1 to 4 years of age (twice that of white children) and older children 5 to 14 years of age and increases in the mortality-disparity ratio in the most recent 10-year period. Two other studies that adjusted for relevant covariates documented significantly higher mortality rates for AA children versus white children in the Detroit tri-county area for boys and older girls (10–19 years old) and among children without congenital anomalies in the state of Michigan. AA children also experience higher risks of death from drowning in a swimming pool, especially in public pools, with the drowning rate in hotel/motel pools disproportionately higher. Significant disease-specific mortality-rate disparities were identified for acute lymphoblastic leukemia (ALL), median age at death for Down syndrome, congenital heart defects (both in terms of the fatality rate and a lower average age at death), and in-hospital death after congenital heart surgery.

Access to Care and Use of Services

Multiple noteworthy disparities were documented in access to health care and use of health services (Table 1). Disparities in access to care include higher rates than those of white children of unmet health care needs, lower rates of access to primary care providers (including race being more strongly associated with this outcome than income), a higher likelihood of having no usual source of care, greater odds of not being referred to a specialist by the health care provider, higher hospitalization rates for ambulatory care–sensitive conditions, and higher odds of appendicitis rupture (considered an access indicator, because it indicates failed access to timely, appropriate care early in the course of appendicitis). Disparities in the use of health services include lower physician-visit rates and higher odds of going 1 year or longer from the last physician visit, a higher rate of emergency department (ED) visits, greater likelihood of medically unnecessary Emergency Medical Services transports, fewer calls to physicians' offices, and, among those with Medicaid coverage, lower odds of well-child care and diagnosis and treatment for various pediatric conditions, and lower expenditures for outpatient and ED care and for prescriptions.

Prevention and Population Health

Disparities were identified in breastfeeding, immunization rates, injuries, obesity, physical activity, and nutrition (Table 1). Breastfeeding is significantly less likely among AA versus white infants, whether measured by ever being breastfed, the proportion exclusively breastfed, or the proportion receiving any human milk. AA children have the lowest immunization rates for the primary immunization series and have substantially greater delays and a later mean age for multiple immunization categories and doses. They have a substantially higher firearm injury rate and, as young children, have higher odds of living in households without stair gates, cabinet safety latches or locks, or hot-water thermostat settings that have been turned down.

Studies consistently document higher rates of obesity and overweight in AA children (Table 1). One study also revealed selection of larger body size when asked to identify ideal adult body size; less personal, family, and peer concern about weight; and fewer children trying to lose weight. Disparities also have been identified in lower aerobic fitness levels, slower 1-mile run/walk time, lower likelihood of vigorous exercise in females, and higher numbers of television-viewing hours. Nutritional disparities include a higher likelihood of consuming more calories as fat and saturated fat, lower mean consumption of fiber and calcium, and lower likelihood of eating breakfast regularly.

Adolescent Health Issues

AA female adolescents have higher risks versus white female adolescents of skipping breakfast, being obese, lacking health insurance, needing but not getting medical care, having any sexually transmitted disease, perpetrating violence, and being a victim of violence (Table 1). Several studies have also documented live birth rates that are 2 to 5 times higher than for white female adolescents, and the disparity ratio has worsened over time. AA female adolescents also have greater adjusted odds of alcohol testing when seen in the ED for traumatic injury and are particularly at high risk of underusing substance abuse services. Male AA adolescents have a higher risk of perpetrating violence and being a victim of violence. For AA adolescents of both genders, higher risks were identified for underuse of substance abuse services, older age at first use of substance abuse services, and suboptimal health status and lower use of physicians' offices as the usual source of care among those recently enrolled in a State Children's Health Insurance Program (SCHIP).

Health Status

Multiple studies have documented health-status disparities for AA children, whether analyzing global health status or the prevalence of specific conditions (Table 1). Three studies revealed that AA children have higher adjusted odds of fair or poor health and lower odds of excellent or very good health. Higher rates of activity limitations, school limitations, and global stress also were noted. Significantly higher crude rates than in white children have been seen for all stroke categories (both hemorrhagic and ischemic), invasive pneumococcal disease, and tuberculosis. HIV/AIDS disparities are substantial, and include the largest percentages and numbers of new diagnoses in every age group of children and adolescents and via perinatal transmission, as well as longer adjusted lengths of stay for those who are hospitalized.

Asthma, Mental Health Care, and Special Health Care Needs

A particularly extensive body of literature is available on disparities for 3 specific issues: asthma, mental health care (including behavioral and developmental issues), and special health care needs (Table 1).

Several studies have documented that AA children have the highest asthma prevalence of any racial/ethnic group, and this prevalence is substantially higher than that for white children (Table 1). Secular-trend data indicate that this disparity has widened over time. Compared with white children, AA children also experience substantially higher rates of asthma mortality, hospitalizations, ED visits, and office visits, and the disparities in asthma mortality and hospitalizations have widened over time. Additional asthma disparities include higher attack prevalence; lower rates of filled prescriptions; higher potential disease burden (diagnosed plus possible but undiagnosed disease); worse asthma physical health scores; lower odds of use of β2-agonists, inhaled steroids, and daily anti-inflammatory medication; and higher odds of sensitivities to cockroach, dust mite, and mold allergens.

Several key disparities were noted in mental health care and behavioral/developmental disorders. Most study results have indicated lower use of mental health services, including lower adjusted odds of any mental health service use, outpatient service use, informal service use (such as self-help and peer counseling), receiving treatment for depression from mental health specialists, and receipt of psychotropic, stimulant, antidepressant, or neuroleptic medications (Table 1). One study, however, found higher odds of use of state-funded mental health services in New York City. Higher adjusted odds of developmental delays have been noted, but underdiagnosis, undertreatment, and other disparities for attention-deficit/hyperactivity disorder (ADHD) were found in other studies, including lower adjusted odds of evaluation, receiving a diagnosis, and receiving medication or treatment, and higher proportions of parents with negative expectations about treatment helpfulness. AA children also were found to receive a diagnosis of autism 1.4 years later than white children and to be in mental health treatment an average of 13 months longer than white children before receiving the autism diagnosis.

National data reveal several disparities for AA children with special health care needs (Table 1), including higher odds of having no regular health care provider, averaging fewer physician visits, being dissatisfied with care, encountering problems with ease of use of services, and not receiving adequate time and information from children's health care providers.

Quality

Numerous disparities were identified in quality of care (Table 1). Lower adjusted odds versus white children were noted for meeting the recommended number of well-child visits and receiving any counseling or screening during well-child visits. Lower adjusted scores were observed for timeliness of care, health insurance plan service, getting needed medical care, primary care comprehensiveness, primary care provider strength of affiliation, and primary care provider interpersonal relationships. Greater adjusted odds were found for the child being assigned to the health care provider; the provider never/only sometimes understanding how the parent prefers to rear the child; and the provider discussing violence in the community, smoking in the household, using alcohol or drugs in household, trouble paying for child's needs, and spouse/partner support of parenting efforts.

Among those with end-stage renal disease, AA children are substantially less likely than white children to be activated on the kidney transplant waiting list but are significantly more likely to receive hemodialysis rather than peritoneal dialysis and to receive an inadequate hemodialysis dose. AA children have lower odds than white children of being diagnosed with any eye or vision condition, are more likely to undergo closed reduction with internal fixation of supracondylar humerus fractures, undergo bidirectional Glenn and Fontan procedures at significantly older ages among those with cardiovascular disease, and have longer time to operation and lengths of stay, higher hospital charges, higher odds of perforation and other complications, and lowers odds of laparoscopic procedures among those with appendicitis. AA patients who have a heart transplant have double the odds of graft failure, lower graft survival rates, a median graft survival time that is 6 years lower, a median age at heart transplant that is 5 years greater, and a higher likelihood of HLA mismatch. AA children are less likely to receive preemptive kidney transplants, and they receive fewer living transplants and more cadaveric transplants.

Asians/Pacific Islanders

There were 24 articles (24 of 109 [22%]) that addressed disparities in API children (Table 2).

View this table:
TABLE 2

Disparities in the Health and Health Care of API Children

Mortality

Only 1 study (Table 2) examined mortality among APIs; it revealed that native Hawaiian children have a higher crude mortality rate than that of white children.

Access to Care and Use of Services

Several studies found disparities for API versus white children in access to health care and use of health services (Table 2). API children have greater adjusted odds of having no usual source of care, having made no visit to a physician or other health care provider in the past year, and going more than 1 year since the last physician visit, as well as a lower adjusted number of physician visits in the past year. Higher adjusted odds of appendicitis rupture also were noted. Among children with cancer, Pacific Islanders had significantly greater odds of death, untimely treatment, not completing treatment as recommended, and loss to follow-up.

Prevention and Population Health

Disparities were identified in injuries, lead intoxication, obesity, and nutrition (Table 2). Data from the state of Minnesota revealed triple the crude firearm injury rate of that in white children. API children were found to have the highest proportion of elevated blood lead concentrations in the state of Rhode Island and are the only racial/ethnic group whose rate increased over time. Higher adjusted odds of overweight occur among Pacific Islander, Filipino, and Asian children, and slower adjusted 1-mile run/walk times were noted for most age groups of API children. API children also have a lower calcium intake—the lowest of any racial/ethnic group.

Adolescent Health Issues

Compared with white adolescents, API adolescents were found to have lower adjusted odds of seatbelt use, sunscreen use, and weekly physical activity and greater adjusted daily hours of television/video-game screen time (Table 2).

Health Status

APIs have a higher adjusted likelihood than that of whites to have fair or poor health status (Table 2). Data from the state of Hawaii revealed that Filipino and Chinese boys have the highest rates of leukemia, and Chinese boys have the highest ALL rate.

Mental Health Care

API children have been found to have lower adjusted odds of any mental health service use, outpatient mental health service use, and 24-hour-care service use (ie, inpatient, residential, group-home, or alcohol/drug abuse treatment) (Table 2). New York City data, however, indicate higher adjusted odds of use of state-funded mental health services.

Quality

Several studies have documented API disparities in primary care quality, including lower overall quality of primary care scores, lower primary care provider interpersonal relationship scores, and lower scores for specific primary care services available to the child (Table 2). Lower adjusted primary care quality scores have been found for 4 elements of care among API parents interviewed in English and 6 elements of care among API parents for whom the primary language spoken at home is not English. Among those hospitalized for pneumonia, API children have lower adjusted odds of bronchoscopy and mechanical ventilation, a longer adjusted length of stay, and higher adjusted charges.

Latinos

There were 66 articles (67 of 109 [61%]) that addressed disparities in Latino children (Table 3).

View this table:
TABLE 3

Disparities in the Health and Health Care of Latino Children

Mortality

Puerto Rican children 1 to 4 years of age were found to have a higher crude mortality rate than their white counterparts (Table 3). A higher drowning rate in neighborhood pools for Latinos also was found, along with higher swimming pool drowning rates in general for Latino male adolescents. Higher adjusted risks of death exist among Latinos (versus whites) with ALL and after congenital heart surgery.

Access to Care and Use of Services

Multiple studies have documented a wide range of disparities in access to care and use of services for Latino children (Table 3). In comparison with white children, Latino children have greater adjusted odds of being uninsured, having no usual source of care or health care provider, having made no physician visit in the past year, having gone 1 year or more since the last physician visit, making fewer physician visits in the past year, making fewer calls to physicians' offices, not being referred to a specialist, having a perforated appendicitis, and never or only sometimes getting medical care without long waits, getting timely routine care or telephone help, and getting brief wait times for medical appointments. Similar findings were noted in studies that focused on Latinos before or at the time of enrollment in SCHIP and among Mexican American children.

Prevention and Population Health

Disparities were identified in breastfeeding, injuries, obesity, physical activity, and nutrition (Table 3). Compared with white infants, a lower crude proportion of Mexican-American infants are ever breastfed. Latino households with children 4 to 35 months of age have lower adjusted odds than do white households of putting up stair gates. Multiple studies have documented significantly higher adjusted odds of overweight and obesity, including 2 studies that showed that Latinos have the highest adjusted rates of overweight and obesity of any racial/ethnic group. Physical-activity disparities included lower adjusted aerobic fitness, slower 1-mile run/walk times, higher average number of television-viewing hours on the average weekday, and lower regular vigorous physical activity among females. Lower calcium intake has been noted, as has as a higher likelihood of consumption of more than 10% of calories as saturated fat.

Adolescent Health Issues

Latina adolescents have a higher risk than do white adolescents of not having health insurance, perpetrating violence, and being a victim of violence. Disparities for male adolescents include a higher risk of no health insurance, going more than 2 years since the last physical examination, and being a victim of violence (Table 3). Latino adolescents recently enrolled in SCHIP have a higher crude likelihood of fair or poor health and are less likely to use physician's offices as their usual source of care. Latina adolescents 15 to 19 years of age have a crude birth rate 3 times higher than their white counterparts and the highest of any racial/ethnic group. Latino adolescents have a lower adjusted odds of being treated in the ED for sexually transmitted diseases, but male Latino adolescents with traumatic injuries have a higher adjusted odds of alcohol testing in the ED. Latino adolescents also have lower adjusted odds of bicycle helmet and sunscreen use.

Health Status

National data reveal a higher adjusted likelihood of fair or poor health in Latinos (Table 3). Compared with whites, Latinos also have twice the percentage of new HIV/AIDS diagnoses among those younger than 13 years old, in perinatal transmission, and among other pediatric cases. They also have a higher crude incidence rate of tuberculosis. In terms of Latino subgroups, both Mexican American and Puerto Rican children have higher adjusted odds of fair or poor health status.

Asthma, Mental Health Care, and Special Health Care Needs

An analysis of national data revealed that Latinos have a higher asthma prevalence than do whites, and there has been a substantial increase in Latino asthma prevalence over time (Table 3). Several studies have documented a particularly high asthma prevalence among Puerto Ricans. Other asthma disparities include higher adjusted odds of asthma ED visits, hospitalizations, activity limitations, and the need for urgent care in the previous 12 months, as well as a higher potential asthma burden (diagnosed plus possible but undiagnosed asthma). Latinos have lower adjusted odds of use of inhaled steroids and of daily anti-inflammatory medications. Disparities among Latino subgroups (compared with white children) include higher adjusted odds of asthma ED visits and hospitalizations among Puerto Ricans, Dominicans, and “other Latinos” (except Mexican Americans) and higher adjusted odds of cockroach and dust mite allergen sensitivity among Mexican Americans.

Eleven studies documented Latino disparities in mental health care and behavioral/developmental issues (Table 3). Disparities included significantly higher unmet need for mental health care, and lower odds of any mental health visit, outpatient visits, antidepressant prescriptions, and receiving treatment from a mental health specialist for any condition, behavior problems, or depression. Latinos have higher odds of developmental delays but lower odds of being diagnosed with externalizing behavioral disorders. Lower odds were noted for use of mental health services among children being investigated for possible abuse or neglect and among Medicaid-eligible teenagers in substance abuse treatment, although 1 study found higher odds of use of state-funded mental health services in New York City. Latinos have substantially lower adjusted odds of receiving an ADHD diagnosis or receiving stimulant prescriptions during outpatient primary care visits. Young Latino children have higher adjusted odds of being read to less than every day, of having fewer numbers of children's books in the household, and of the family never eating lunch or dinner together.

Many disparities have been documented for Latino children with special health care needs, including higher adjusted odds of being uninsured, having no usual source of care, parental dissatisfaction with care, having unmet medical care needs, not having seen the physician in the past year, not receiving adequate time and information from the health care provider, averaging fewer doctor visits per year, experiencing difficulties receiving specialty referrals, having family members reduce or stop employment because of the child's condition, not receiving family-centered care, and experiencing problems with ease of use of health care services.

Quality

Compared with white children, Latino children have higher adjusted odds of being assigned to a health care provider and lower adjusted scores for comprehensiveness of primary care and primary care provider strength of affiliation, interpersonal relationship, and participatory decision-making (Table 3). Latino children have a shorter average well-child visit duration, lower adjusted odds of receiving any counseling during well-child visits, and greater adjusted odds of the parent not being very likely to recommend the child's health care provider, of the health care provider never or only sometimes understanding the child's specific needs and how the parent prefers to rear the child, and of the provider discussing violence in the community and use of alcohol or drugs in the household. Similar disparities in the quality of primary care were noted for Latino children living in households in which English is not the primary language spoken (in comparison with white children).

Among those seen in the ED with acute gastroenteritis, Latino children had lower adjusted odds than white children of undergoing 2 or more diagnostic tests and of having undergone radiography (Table 3). Among children with supracondylar humerus fractures, Latinos were more likely to undergo closed reduction with internal fixation.

American Indians and Alaska Natives

Sixteen articles (15%) addressed disparities in AI/AN children, which is the fewest articles for any racial/ethnic group (Table 4).

View this table:
TABLE 4

Disparities in the Health and Health Care of AI/AN Children

Mortality

AI/AN children have a higher age-specific crude mortality rate compared with that of white children, both in national and urban samples (Table 4). A higher adjusted risk of death also has been documented for AI/AN children with ALL.

Use of Health Services

AI/AN children have higher adjusted odds than white children of going 1 year or longer since their last physician visit (Table 4).

Prevention and Population Health

Data from the state of Minnesota reveal a firearm injury rate for AI/AN children that is more than 7 times higher than that for their white counterparts (Table 4). Several studies have documented higher adjusted odds of overweight and obesity among AI/AN children. Other studies have shown a slower adjusted 1-mile run/walk time and lower calcium intake among AI/AN boys.

Adolescent Health Issues

Female AI/AN adolescents have higher risks than their white counterparts of needing but not getting medical care and of perpetrating violence (Table 4). Male AI/AN adolescents have a higher risk than their white counterparts of skipping breakfast, having poor/fair health status, and perpetrating violence. National data from 2 studies revealed that the birth rate for AI/AN female adolescents is 2 to 3 times higher than that of white adolescents.

Health Status

AI/AN children have higher adjusted odds than do white children of being in poor or fair health and the highest prevalence of these suboptimal health ratings of any racial/ethnic group (Table 4).

Mental Health Care

Within 6 months of a new episode of depression, AI/AN children have lower adjusted odds than white children of any mental health visit or antidepressant prescription being filled. AI/AN youth in treatment for substance abuse also have a lower adjusted likelihood of mental health services use.

Quality

Compared with the parents of white children, the parents of AI/AN children gave lower adjusted scores for their child's health care timeliness, health care provider communication, and health insurance plan service, and lower adjusted ratings for their child's personal doctor and health plan (Table 4). National data also reveal lower adjusted odds of being diagnosed with any eye or vision condition.

Multiracial Children

The search terms did not yield any articles on disparities among multiracial children.

DISPARITIES AMONG RACIAL/ETHNIC SUBGROUPS

Fifteen studies (14%) included analyses of disparities in 1 or more racial/ethnic subgroup (in comparison with white children). Five studies of APIs (21% of all studies of APIs) and 10 studies of Latinos (15% of all studies of Latinos) examined racial/ethnic subgroup disparities; none of the analyses for AA or AI/AN children included subgroup analyses.

STUDIES EVALUATING INTERVENTIONS TO REDUCE DISPARITIES

The search terms yielded only 2 studies that evaluated interventions to reduce racial/ethnic disparities (Table 5). A quasi-experimental evaluation of a school-based Internet and video intervention that focused on health snacks and gym labs resulted in significant reductions in dietary fat intake among all 3 minority groups as well as among those in the white group, and significant increases in physical activity among low-income children in all 3 minority groups and white children. It was unclear, however, what the control group received, there was no overall difference between intervention and control children in fat-intake reduction, and participants in both the intervention and control groups decreased their amount of physical activity.

View this table:
TABLE 5

Results of Studies Evaluating Interventions to Reduce Disparities in the Health and Health Care of Minority Children

A preintervention and postintervention study in an upstate New York county of the effects of a community-wide reminder, recall, and outreach system for childhood immunizations resulted in no statistically significant differences from 24-month-old white children in postintervention immunization rates for 24-month-old AA and Latino children, and no statistically significant difference between only Latino and white 12-month-old children in postintervention immunization rates. Up to 74% of the cohort, however, did not receive the intervention in some county regions, and the immunization rates were not adjusted for confounders.

METHODOLOGIC ISSUES

Failure to evaluate children separately from adults was the most common reason for exclusion of studies from the final database, accounting for 27 (22%) of the excluded studies. Another commonly encountered methodologic issue was the combination of all nonwhite children into 1 group, which occurred in 11 (9%) of the excluded studies. An additional 10 studies (8%) failed to provide a white comparison group. Among the 109 studies in the final database, 27 (22%) did not perform multivariable or stratified analyses to ensure that racial/ethnic disparities persisted after adjustment for socioeconomic status (SES) and other potential confounders.

IMPLICATIONS

Extensiveness and Pervasiveness of Disparities

A comprehensive review of the literature revealed that racial/ethnic disparities in children's health and health care are quite extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. In addition, the data indicate that racial/ethnic disparities are persisting or worsening over time, at least in the few areas for which data from secular-trend studies are available, such as overall mortality rates, elevated blood lead concentrations, and asthma prevalence, mortality, and hospitalizations.

Mortality and Chronic Disease

Although racial/ethnic disparities in adult mortality21 and chronic disease22 rates have received much attention, little attention has been paid to these issues in children (other than for infant mortality). Nevertheless, review of the literature identified disparities in mortality rates for all 4 major racial/ethnic groups of US children. The extent and diversity of these mortality-rate disparities are concerning: these disparities include substantially greater risks than for white children of all-cause mortality; death from drowning, from ALL, from congenital heart defects, and after congenital heart defect surgery; and an earlier median age at death for those with Down syndrome and congenital heart defects. Additional research is needed to determine whether other racial/ethnic disparities exist in childhood mortality rates, the causes of these disparities, and interventions that are effective in reducing or eliminating mortality-rate disparities.

Extensive childhood disparities were found for chronic diseases, including asthma, cancer, eye disorders, HIV/AIDS, kidney disease, mental health, special health care needs, and stroke. In particular, multiple studies have been conducted on disparities in asthma, mental health, and special health care needs. Nevertheless, many gaps exist in the literature, and further study is needed to determine the etiology of and effective interventions for disparities in childhood chronic diseases.

Disparities as a Quality Issue

It has been suggested that a useful approach to addressing racial/ethnic disparities in children's health care is to frame disparities as a quality-of-care issue.23 This review of the literature identified multiple racial/ethnic disparities in the quality of children's health care, including inequalities in the quality of primary care, asthma care, cardiovascular surgery, mental health care, pneumonia hospitalizations, ophthalmologic care, orthopedic conditions, and care of children with end-stage renal disease. Additional study is warranted, not only of the etiology and pervasiveness of disparities in the quality of pediatric care, but also of interventions that would be effective in achieving quality improvement among racial/ethnic minority children.

Research Implications

In the course of reviewing the disparities literature, certain key methodologic and research issues were identified. Attention to these issues has the potential to advance the field and enhance the rigor of studies. A total of 48 studies were excluded from the database because they combined all minority children into a nebulous “nonwhite” category, failed to include a comparison group consisting of white children, or did not perform separate analyses with children disaggregated from adults.

Occasionally, there may be statistically legitimate reasons to not compare study findings for specific minority racial/ethnic groups with those of white children (such as when there truly are small sample sizes for specific minority groups in the study population). The recurrent findings in the literature, however, of combining minority children into a “nonwhite group” and failure to collect data for specific, populous minority groups of children raise several key issues. It is critical that current and future pediatric research be relevant, meaningful, and generalizable for all children. The explosive growth in racial/ethnic diversity of US children makes it imperative that pediatric research funding not ignore specific questions or populations. In addition, as new interventions, practices, and technologies are evaluated, it is important to consider translational research on the application of these innovations to diverse populations and settings.

Almost one-quarter of the excluded studies did not use multivariable or stratified analyses to adjust for covariates that might confound disparities findings. For several domains, such as mental health, asthma, and vision disorders, there is an unresolved issue that warrants further investigation; it is unclear whether (1) a general quality issue exists for minority children of underdiagnosis and undertreatment of certain conditions, (2) there is a lower prevalence of these conditions in certain groups, (3) racial/ethnic differences occur in access or treatment preferences, or (4) some combination of these phenomena apply.

More disparities research is needed on API and AI/AN children, because a paucity of studies on these groups was identified. The few studies that examined relevant subgroups of racial/ethnic minority children identified noteworthy racial/ethnic disparities. More research is needed on childhood disparities among black subgroups (such as AAs versus Caribbean blacks versus recent African immigrants), Latinos (such as Mexican Americans, Puerto Ricans, and Cuban Americans), AIs/ANs (such as major tribal groups), and APIs (such as Chinese Americans versus Vietnamese versus Hmong). Our call for more studies on racial/ethnic subgroup disparities echoes a recommendation published 15 years ago by the AAP Task Force on Minority Children's Access to Pediatric Care that more attention be paid to the heterogeneity of API populations.24

Limitations

Certain limitations of this literature review should be noted. The literature search consisted of studies from 1950 through March 2007, so studies after March could not be included. Because the search strategies only identified published citations with “disparities” as a key word, studies that reported disparities or disparities interventions but did not use this key word would have been missed; in particular, research from earlier years before the “disparities” term enjoyed wider usage would have been overlooked. The focus was on racial/ethnic disparities, so studies that documented a lack of disparities were not reviewed. Only 21 studies, however, were excluded that found no significant differences according to race/ethnicity, equivalent to 9% of the database of full-print studies examined, and 17% of all exclusions.

Interventions to Reduce Disparities

This literature review identified only 2 studies that evaluated interventions to reduce racial/ethnic disparities in children's health and health care and that also compared the minority group to a white group, and none was a randomized, controlled trial. These findings suggest that there is a need for rigorous evaluations of interventions aimed at reducing childhood disparities, especially in light of the substantial number of studies identified that documented a wide variety of racial/ethnic disparities in children's health and health care.

Only articles that examined racial/ethnic disparities in the context of comparisons to white children were included in the literature review. For certain health outcomes for which racial/ethnic disparities are well documented, published studies may only have focused on disparities interventions limited to a single minority group. Because the literature-search inclusion criteria required comparison between a minority group and a white group, successful disparities-intervention studies limited to a single minority group were excluded, by necessity, from this technical report, such as recent randomized trials of interventions to insure uninsured Latino children and prevent HIV in AA girls.25,26

CONCLUSIONS

This technical report documents that racial/ethnic disparities in children's health and health care are extensive, pervasive, and persistent. Disparities were noted across the spectrum of health and health care, including in mortality rates, access to care and use of services, prevention and population health, health status, adolescent health, chronic diseases, special health care needs, quality of care, and organ transplantation. Methodologic flaws were identified in how such disparities are documented and analyzed. Without recognition of child health disparities as pervasive problems, sound methodologies to assess the magnitude of disparities, and rigorous evaluation of disparities interventions, the pediatric community will not be able to realize the vision of the AAP to attain optimal physical, mental, and social health and well-being of all infants, children, adolescents, and young adults.

COMMITTEE ON PEDIATRIC RESEARCH, 2008–2009

  • Scott C. Denne, MD, Chairperson

  • Andrew J. Bauer, MD

  • *Michael D. Cabana, MD, MPH

  • Tina L. Cheng, MD

  • †Glenn Flores, MD

  • Daniel A. Notterman, MD

LIAISONS

  • Duane F. Alexander, MD

  • Eunice Kennedy Shriver National Institute of Child Health and Human Development

  • Clifford W. Bogue, MD

  • Society for Pediatric Research

  • Laurence A. Boxer, MD

  • American Pediatric Society

  • Christopher A. DeGraw, MD, MPH

  • Maternal and Child Health Bureau

  • Denise Dougherty, PhD

  • Agency for Healthcare Research and Quality

  • Benard P. Dreyer, MD

  • Academic Pediatric Association

  • Elizabeth Goodman, MD

  • Society for Adolescent Medicine

  • A. Craig Hillemeier, MD

  • Association of Medical School Pediatric Department Chairs

  • Lewis H. Margolis, MD, MPH

  • American Public Health Association

  • Jessica Shand, MD

  • AAP Section on Residents

  • Paul P. Wang, MD

  • Society for Developmental and Behavioral Pediatrics

STAFF

  • William L. Cull, PhD

  • *Contributing author

  • †Lead author

Footnotes

  • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

  • The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

  • All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

  • CDC =
    Centers for Disease Control and Prevention •
    CI =
    confidence interval •
    AAP =
    American Academy of Pediatrics •
    AA =
    African American •
    API =
    Asian/Pacific Islander •
    AI/AN =
    American Indian/Alaska Native •
    ALL =
    acute lymphoblastic leukemia •
    ED =
    emergency department •
    SCHIP =
    State Children's Health Insurance Program •
    ADHD =
    attention-deficit/hyperactivity disorder •
    SES =
    socioeconomic status

REFERENCES

  1. 1.↵
    Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2007. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2008. AHRQ publication 08–0041
  2. 2.↵
    Agency for Healthcare Research and Quality. National Healthcare Disparities Report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2003. Available at: www.ahrq.gov/qual/nhdr03/nhdr2003.pdf. Accessed August 20, 2009
  3. 3.↵
    US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: US Government Printing Office; 2000
  4. 4.↵
    National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services.Health Disparities: Bridging the Gap. Washington, DC: US Government Printing Office; 2000
  5. 5.↵
    Centers for Disease Control and Prevention. Achieving greater health impact: CDC's strategic imperatives. Available at: www.cdc.gov/osi/goals/SIHPGPostcard.pdf. Accessed August 20, 2009
  6. 6.↵
    National Institutes of Health. The NIH Almanac: National Center on Minority Health and Health Disparities. Available at: www.nih.gov/about/almanac/organization/NCMHD.htm. Accessed August 20, 2009
  7. 7.↵
    1. Smedley BD,
    2. Stith AY,
    3. Nelson AR
    eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003
  8. 8.↵
    S 4024: Minority Health Improvement and Health Disparity Elimination Act (2006). Available at: www.govtrack.us/congress/bill.xpd?bill=s109-4024. Accessed August 20, 2009
  9. 9.↵
    US Department of Health and Human Services, Health Resources and Services Administration. HRSA Releases New Document on Eliminating Health Disparities [press release]. Washington, DC: US Department of Health and Human Services; 2001
  10. 10.↵
    1. Wise PH
    . The anatomy of a disparity in infant mortality. Annu Rev Public Health. 2003; 24: 341–362
    OpenUrlCrossRefPubMed
  11. 11.↵
    US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000
  12. 12.↵
    American Academy of Pediatrics, Committee on Pediatric Workforce. Enhancing the diversity of the pediatrician workforce. Pediatrics. 2007; 119(4): 833–837
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    US Census Bureau. United States: S0901—children characteristics. Available at: http://factfinder.census.gov/servlet/STTable?_bm=y&-qr_name=ACS_2006_EST_G00_S0901&-geo_id=01000US&-ds_name=ACS_2006_EST_G00_&-_lang=en&-format=&CONTEXT=st. Accessed August 20, 2009
  14. 14.↵
    US Census Bureau. Census 2000 PHC-T-8: race and Hispanic or Latino origin by age and sex for the United States: 2000. Table 8: Hispanic or Latino origin population; white alone not-Hispanic or Latino origin population; and population other than white alone not-Hispanic or Latino origin, by age and sex for the United States: 2000. Available at: www.census.gov/population/cen2000/phc-t08/tab08.pdf. Accessed August 20, 2009
  15. 15.↵
    1. Annie E
    . Casey Foundation. Kids Count census data online: 2000 census data—summary profile for United States. Selected demographic characteristics for children: 1990 and 2000. Available at: www.kidscount.org/cgi-bin/aeccensus.cgi?action=profileresults&area=00N&areaparent=00N&printerfriendly=0&section=0. Accessed August 20, 2009
  16. 16.↵
    Brookings Institution Center on Urban and Metropolitan Policy. Racial change in the nation's largest cities: evidence from the 2000 census. Available at: www.brookings.edu/es/urban/census/citygrowth.htm. Accessed August 20, 2009
  17. 17.↵
    US Census Bureau. DP-1: profile of general demographic characteristics—2000. California. Available at: http://factfinder.census.gov/servlet/QTTable?_bm=y&-geo_id=04000US06&-qr_name=DEC_2000_SF1_U_DP1&-ds_name=DEC_2000_SF1_U&-_lang=en&-_sse=on. Accessed August 20, 2009
  18. 18.↵
    US Census Bureau.California: general demographic characteristics: 2005. Available at: http://factfinder.census.gov/servlet/ADPTable?_bm=y&-geo_id=04000US06&-qr_name=ACS_2005_EST_G00_DP1&-ds_name=ACS_2005_EST_G00_&-_lang=en&-_sse=on. Accessed August 20, 2009
  19. 19.↵
    US Census Bureau. (NP-T4-F) Projections of the total resident population by 5-year age groups, race, and Hispanic origin with special age categories: middle series, 2025 to 2045. Available at: www.census.gov/population/projections/nation/summary/np-t4-f.pdf. Accessed August 20, 2009
  20. 20.↵
    US Census Bureau.Minority population tops 100 million [press release]. Available at: www.census.gov/Press-Release/www/releases/archives/population/010048.html. Accessed August 20, 2009
  21. 21.↵
    1. Williams DR,
    2. Jackson PB
    . Social sources of racial disparities in health. Health Aff (Millwood). 2005; 24(2): 325–334
    OpenUrlAbstract/FREE Full Text
  22. 22.↵
    1. Redmond LJ,
    2. Bowman BA,
    3. Mensah GA
    . Health Disparities: A Selected Bibliography From the National Center for Chronic Disease Prevention and Health Promotion—January 2000–January 2005. Atlanta, GA: Centers for Disease Control and Prevention; 2005
  23. 23.↵
    1. Beal AC
    . Policies to reduce racial and ethnic disparities in child health and health care.Health Aff (Millwood). 2004; 23(5): 171–179
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    American Academy of Pediatrics, Task Force on Minority Children's Access to Pediatric Care. Report of the AAP Task Force on Minority Children's Access to Pediatric Care. Elk Grove Village, IL: American Academy of Pediatrics; 1994
  25. 25.↵
    1. Flores G,
    2. Abreu M,
    3. Chaisson CE,
    4. et al
    . A randomized trial of the effectiveness of community-based case management in insuring uninsured Latino children. Pediatrics. 2005; 116(6): 1433–1441
    OpenUrlAbstract/FREE Full Text
  26. 26.↵
    1. DiClemente RJ,
    2. Wingood GM,
    3. Harrington KF,
    4. et al
    . Efficacy of an HIV prevention intervention for African American adolescent girls: a randomized controlled trial. JAMA. 2004; 292(2): 171–179
    OpenUrlCrossRefPubMed
  27. 27.↵
    1. Guagliardo MF,
    2. Ronzio CR,
    3. Cheung I,
    4. Chacko E,
    5. Joseph JG
    . Physician accessibility: an urban case study of pediatric providers. Health Place. 2004; 10(3): 273–283
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Shi L,
    2. Stevens GD
    . Disparities in access to care and satisfaction among U.S. children: the roles of race/ethnicity and poverty status. Public Health Rep. 2005; 120(4): 431–441
    OpenUrlPubMed
  29. 29.↵
    1. Guagliardo MF,
    2. Teach SJ,
    3. Huang ZJ,
    4. Chamberlain JM,
    5. Joseph JG
    . Racial and ethnic disparities in pediatric appendicitis rupture rate. Acad Emerg Med. 2003; 10(11): 1218–1227
    OpenUrlCrossRefPubMed
  30. 30.↵
    1. Shone LP,
    2. Dick AW,
    3. Brach C,
    4. et al
    . The role of race and ethnicity in the State Children's Health Insurance Program (SCHIP) in four states: are there baseline disparities, and what do they mean for SCHIP?Pediatrics. 2003; 112(6 pt 2). Available at: www.pediatrics.org/cgi/content/full/112/6/SE1/e521
  31. 31.↵
    1. Shone LP,
    2. Dick AW,
    3. Klein JD,
    4. Zwanziger J,
    5. Szilagyi PG
    . Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program. Pediatrics. 2005; 115(6). Available at: www.pediatrics.org/cgi/content/full/115/6/e697
  32. 32.↵
    1. Flores G,
    2. Olson L,
    3. Tomany-Korman SC
    . Racial and ethnic disparities in early childhood health and health care. Pediatrics. 2005; 115(2). Available at: www.pediatrics.org/cgi/content/full/115/2/e183
  33. 33.↵
    1. Klein JD,
    2. Shenkman E,
    3. Brach C,
    4. et al
    . Prior health care experiences of adolescents who enroll in SCHIP. J Health Care Poor Underserved. 2006; 17(4): 789–807
    OpenUrlCrossRefPubMed
  34. 34.↵
    1. Heflinger CA,
    2. Chatman J,
    3. Saunders RC
    . Racial and gender differences in utilization of Medicaid substance abuse services among adolescents. Psychiatr Serv. 2006; 57(4): 504–511
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Harris KM,
    2. Gordon-Larsen P,
    3. Chantala K,
    4. Udry JR
    . Longitudinal trends in race/ethnic disparities in leading health indicators from adolescence to young adulthood. Arch Pediatr Adolesc Med. 2006; 160(1): 74–81
    OpenUrlCrossRefPubMed
  36. 36.↵
    1. Keppel KG,
    2. Pearcy JN,
    3. Wagener DK
    . Trends in racial and ethnic-specific rates for the health status indicators: United States, 1990–98. Healthy People 2000 Stat Notes. 2002;(23): 1–16
  37. 37.↵
    1. Margellos H,
    2. Silva A,
    3. Whitman S
    . Comparison of health status indicators in Chicago: are black-white disparities worsening?Am J Public Health. 2004; 94(1): 116–121
    OpenUrlPubMed
  38. 38.↵
    1. Arias E,
    2. MacDorman MF,
    3. Strobino DM,
    4. Guyer B
    . Annual summary of vital statistics: 2002. Pediatrics. 2003; 112(6 pt 1): 1215–1230
    OpenUrlAbstract/FREE Full Text
  39. 39.↵
    1. Marcin JP,
    2. Pretzlaff RK,
    3. Whittaker HL,
    4. Kon AA
    . Evaluation of race and ethnicity on alcohol and drug testing of adolescents admitted with trauma. Acad Emerg Med. 2003; 10(11): 1253–1259
    OpenUrlCrossRefPubMed
  40. 40.↵
    1. Akinbami LJ,
    2. Schoendorf KC
    . Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics. 2002; 110(2 pt 1): 315–322
    OpenUrlAbstract/FREE Full Text
  41. 41.↵
    1. McDaniel M,
    2. Paxson C,
    3. Waldfogel J
    . Racial disparities in childhood asthma in the United States: evidence from the National Health Interview Survey, 1997 to 2003. Pediatrics. 2006; 117(5). Available at: www.pediatrics.org/cgi/content/full/117/5/e868
  42. 42.↵
    1. Pearlman DN,
    2. Zierler S,
    3. Meersman S,
    4. Kim HK,
    5. Viner-Brown SI,
    6. Caron C
    . Race disparities in childhood asthma: does where you live matter?J Natl Med Assoc. 2006; 98(2): 239–247
    OpenUrlPubMed
  43. 43.↵
    1. Guevara JP,
    2. Mandell DS,
    3. Rostain AL,
    4. Zhao H,
    5. Hadley TR
    . Disparities in the reporting and treatment of health conditions in children: an analysis of the Medical Expenditure Panel Survey. Health Serv Res. 2006; 41(2): 532–549
    OpenUrlCrossRefPubMed
  44. 44.↵
    1. McCoy L,
    2. Redelings M,
    3. Sorvillo F,
    4. Simon P
    . A multiple cause-of-death analysis of asthma mortality in the United States, 1990–2001. J Asthma. 2005; 42(9): 757–763
    OpenUrlCrossRefPubMed
  45. 45.↵
    1. Stingone JA,
    2. Claudio L
    . Disparities in the use of urgent health care services among asthmatic children. Ann Allergy Asthma Immunol. 2006; 97(2): 244–250
    OpenUrlPubMed
  46. 46.↵
    1. Quinn K,
    2. Shalowitz MU,
    3. Berry CA,
    4. Mijanovich T,
    5. Wolf RL
    . Racial and ethnic disparities in diagnosed and possible undiagnosed asthma among public-school children in Chicago. Am J Public Health. 2006; 96(9): 1599–1603
    OpenUrlCrossRefPubMed
  47. 47.↵
    1. Roberts EM
    . Racial and ethnic disparities in childhood asthma diagnosis: the role of clinical findings. J Natl Med Assoc. 2002; 94(4): 215–223
    OpenUrlPubMed
  48. 48.↵
    1. Lieu TA,
    2. Lozano P,
    3. Finkelstein JA,
    4. et al
    . Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics. 2002; 109(5): 857–865
    OpenUrlAbstract/FREE Full Text
  49. 49.↵
    1. Stevenson LA,
    2. Gergen PJ,
    3. Hoover DR,
    4. Rosenstreich D,
    5. Mannino DM,
    6. Matte TD
    . Sociodemographic correlates of indoor allergen sensitivity among United States children. J Allergy Clin Immunol. 2001; 108(5): 747–752
    OpenUrlCrossRefPubMed
  50. 50.↵
    1. Simon PA,
    2. Zeng Z,
    3. Wold CM,
    4. Haddock W,
    5. Fielding JE
    . Prevalence of childhood asthma and associated morbidity in Los Angeles County: impacts of race/ethnicity and income. J Asthma. 2003; 40(5): 535–543
    OpenUrlCrossRefPubMed
  51. 51.↵
    1. Ortega AN,
    2. Gergen PJ,
    3. Paltiel AD,
    4. Bauchner H,
    5. Belanger KD,
    6. Leaderer BP
    . Impact of site of care, race, and Hispanic ethnicity on medication use for childhood asthma. Pediatrics. 2002; 109(1). Available at: www.pediatrics.org/cgi/content/full/109/1/e1
  52. 52.↵
    1. Smith LA,
    2. Hatcher-Ross JL,
    3. Wertheimer R,
    4. Kahn RS
    . Rethinking race/ethnicity, income, and childhood asthma: racial/ethnic disparities concentrated among the very poor. Public Health Rep. 2005; 120(2): 109–120
    OpenUrlPubMed
  53. 53.↵
    1. Li R,
    2. Grummer-Strawn L
    . Racial and ethnic disparities in breastfeeding among United States infants: Third National Health and Nutrition Examination Survey, 1988–1994. Birth. 2002; 29(4): 251–257
    OpenUrlCrossRefPubMed
  54. 54.↵
    1. Fullerton HJ,
    2. Wu YW,
    3. Zhao S,
    4. Johnston SC
    . Risk of stroke in children: ethnic and gender disparities. Neurology. 2003; 61(2): 189–194
    OpenUrlAbstract/FREE Full Text
  55. 55.↵
    1. Stevens GD,
    2. Seid M,
    3. Mistry R,
    4. Halfon N
    . Disparities in primary care for vulnerable children: the influence of multiple risk factors. Health Serv Res. 2006; 41(2): 507–531
    OpenUrlCrossRefPubMed
  56. 56.↵
    1. Chen E,
    2. Martin AD,
    3. Matthews KA
    . Understanding health disparities: the role of race and socioeconomic status in children's health. Am J Public Health. 2006; 96(4): 702–708
    OpenUrlCrossRefPubMed
  57. 57.↵
    1. Goodman E,
    2. McEwen BS,
    3. Dolan LM,
    4. Schafer-Kalkhoff T,
    5. Adler NE
    . Social disadvantage and adolescent stress. J Adolesc Health. 2005; 37(6): 484–492
    OpenUrlCrossRefPubMed
  58. 58.↵
    1. Stevens GD
    . Gradients in the health status and developmental risks of young children: the combined influences of multiple social risk factors. Matern Child Health J. 2006; 10(2): 187–199
    OpenUrlCrossRefPubMed
  59. 59.↵
    Centers for Disease Control and Prevention. Racial/ethnic disparities in diagnoses of HIV/AIDS: 33 states, 2001–2004. MMWR Morb Mortal Wkly Rep. 2006; 55(5): 121–125
    OpenUrlPubMed
  60. 60.↵
    1. Rutstein RM,
    2. Gebo KA,
    3. Siberry GK,
    4. et al
    . Hospital and outpatient health services utilization among HIV-infected children in care 2000–2001. Med Care. 2005; 43(9 suppl): III31–III39
    OpenUrlPubMed
  61. 61.↵
    1. Parker JD,
    2. Schoendorf KC
    . Variation in hospital discharges for ambulatory care-sensitive conditions among children. Pediatrics. 2000; 106(4 suppl): 942–948
    OpenUrlPubMed
  62. 62.↵
    1. Dominguez SR,
    2. Parrott JS,
    3. Lauderdale DS,
    4. Daum RS
    . On-time immunization rates among children who enter Chicago public schools. Pediatrics. 2004; 114(6). Available at: www.pediatrics.org/cgi/content/full/114/6/e741
  63. 63.↵
    1. Flannery B,
    2. Schrag S,
    3. Bennett NM,
    4. et al
    . Impact of childhood vaccination on racial disparities in invasive Streptococcus pneumoniae infections. JAMA. 2004; 291(18): 2197–2203
    OpenUrlCrossRefPubMed
  64. 64.↵
    1. Stout JE,
    2. Saharia KK,
    3. Nageswaran S,
    4. Ahmed A,
    5. Hamilton CD
    . Racial and ethnic disparities in pediatric tuberculosis in North Carolina. Arch Pediatr Adolesc Med. 2006; 160(6): 631–637
    OpenUrlCrossRefPubMed
  65. 65.↵
    1. Roesler J,
    2. Ostercamp M
    . Pediatric firearm injury in Minnesota, 1998: fatal and nonfatal firearm injuries among Minnesota youth. Minn Med. 2000; 83(9): 57–60
    OpenUrlPubMed
  66. 66.↵
    1. Flores G,
    2. Tomany-Korman SC,
    3. Olson L
    . Does disadvantage start at home? Racial and ethnic disparities in health-related early childhood home routines and safety practices. Arch Pediatr Adolesc Med. 2005; 159(2): 158–165
    OpenUrlCrossRefPubMed
  67. 67.↵
    1. Zimmerman FJ
    . Social and economic determinants of disparities in professional help-seeking for child mental health problems: evidence from a national sample. Health Serv Res. 2005; 40(5 pt 1): 1514–1533
    OpenUrlCrossRefPubMed
  68. 68.↵
    1. Pastor PN,
    2. Reuben CA
    . Racial and ethnic differences in ADHD and LD in young school-age children: parental reports in the National Health Interview Survey. Public Health Rep. 2005; 120(4): 383–392
    OpenUrlPubMed
  69. 69.↵
    1. Garland AF,
    2. Lau AS,
    3. Yeh M,
    4. McCabe KM,
    5. Hough RL,
    6. Landsverk JA
    . Racial and ethnic differences in utilization of mental health services among high-risk youths. Am J Psychiatry. 2005; 162(7): 1336–1343
    OpenUrlCrossRefPubMed
  70. 70.↵
    1. Mandell DS,
    2. Listerud J,
    3. Levy S,
    4. Pinto-Martin JA
    . Race differences in the age at diagnosis among Medicaid-eligible children with autism. J Am Acad Child Adolesc Psychiatry. 2002; 41(12): 1447–1453
    OpenUrlCrossRefPubMed
  71. 71.↵
    1. Bussing R,
    2. Zima BT,
    3. Gary FA,
    4. Garvan CW
    . Barriers to detection, help-seeking, and service use for children with ADHD symptoms. J Behav Health Serv Res. 2003; 30(2): 176–189
    OpenUrlCrossRefPubMed
  72. 72.↵
    1. Chow JC,
    2. Jaffee K,
    3. Snowden L
    . Racial/ethnic disparities in the use of mental health services in poverty areas. Am J Public Health. 2003; 93(5): 792–797
    OpenUrlCrossRefPubMed
  73. 73.↵
    1. Hurlburt MS,
    2. Leslie LK,
    3. Landsverk J,
    4. et al
    . Contextual predictors of mental health service use among children open to child welfare. Arch Gen Psychiatry. 2004; 61(12): 1217–1224
    OpenUrlCrossRefPubMed
  74. 74.↵
    1. Zito JM,
    2. Safer DJ,
    3. Zuckerman IH,
    4. Gardner JF,
    5. Soeken K
    . Effect of Medicaid eligibility category on racial disparities in the use of psychotropic medications among youths. Psychiatr Serv. 2005; 56(2): 157–163
    OpenUrlCrossRefPubMed
  75. 75.↵
    1. Saluja G,
    2. Brenner RA,
    3. Trumble AC,
    4. Smith GS,
    5. Schroeder T,
    6. Cox C
    . Swimming pool drownings among US residents aged 5–24 years: understanding racial/ethnic disparities. Am J Public Health. 2006; 96(4): 728–733
    OpenUrlCrossRefPubMed
  76. 76.↵
    1. Hillemeier MM,
    2. Geronimus AT,
    3. Bound SJ
    . Widening black/white mortality differentials among US children during the 1980s. Ethn Dis. 2001; 11(3): 469–483
    OpenUrlPubMed
  77. 77.↵
    Centers for Disease Control and Prevention. Racial disparities in median age at death of persons with Down syndrome: United States, 1968–1997. MMWR Morbid Mortal Wkly Rep. 2001; 50(22): 463–465
    OpenUrlPubMed
  78. 78.↵
    1. Boneva RS,
    2. Botto LD,
    3. Moore CA,
    4. Yang Q,
    5. Correa A,
    6. Erickson JD
    . Mortality associated with congenital heart defects in the United States: trends and racial disparities, 1979–1997. Circulation. 2001; 103(19): 2376–2381
    OpenUrlAbstract/FREE Full Text
  79. 79.↵
    1. Singh GK,
    2. Yu SM
    . US childhood mortality, 1950 through 1993: trends and socioeconomic differentials. Am J Public Health. 1996; 86(4): 505–512
    OpenUrlPubMed
  80. 80.↵
    1. Berger KH,
    2. Zhu BP,
    3. Copeland G
    . Mortality throughout early childhood for Michigan children born with congenital anomalies, 1992–1998. Birth Defects Res A Clin Mol Teratol. 2003; 67(9): 656–661
    OpenUrlCrossRefPubMed
  81. 81.↵
    1. Kadan-Lottick NS,
    2. Ness KK,
    3. Bhatia S,
    4. Gurney JG
    . Survival variability by race and ethnicity in childhood acute lymphoblastic leukemia. JAMA. 2003; 290(15): 2008–2014
    OpenUrlCrossRefPubMed
  82. 82.↵
    1. Benavidez OJ,
    2. Gauvreau K,
    3. Jenkins KJ
    . Racial and ethnic disparities in mortality following congenital heart surgery. Pediatr Cardiol. 2006; 27(3): 321–328
    OpenUrlCrossRefPubMed
  83. 83.↵
    1. Furth SL,
    2. Powe NR,
    3. Hwang W,
    4. Neu AM,
    5. Fivush BA
    . Racial differences in choice of dialysis modality for children with end-stage renal disease. Pediatrics. 1997: 99(4). Available at: www.pediatrics.org/cgi/content/full/99/4/e6
  84. 84.↵
    1. Leonard MB,
    2. Stablein DM,
    3. Ho M,
    4. Jabs K,
    5. Feldman HI
    . Racial and center differences in hemodialysis adequacy in children treated at pediatric centers: a North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) report. J Am Soc Nephrol. 2004; 15(11): 2923–2932
    OpenUrlAbstract/FREE Full Text
  85. 85.↵
    1. Furth SL,
    2. Garg PP,
    3. Neu AM,
    4. Hwang W,
    5. Fivush BA,
    6. Powe NR
    . Racial differences in access to the kidney transplant waiting list for children and adolescents with end-stage renal disease. Pediatrics. 2000; 106(4): 756–761
    OpenUrlAbstract/FREE Full Text
  86. 86.↵
    1. Adams K,
    2. Sargent RG,
    3. Thompson SH,
    4. Richter D,
    5. Corwin SJ,
    6. Rogan TJ
    . A study of body weight concerns and weight control practices of 4th and 7th grade adolescents. Ethn Health. 2000; 5(1): 79–94
    OpenUrlCrossRefPubMed
  87. 87.↵
    1. Shaibi GQ,
    2. Ball GD,
    3. Goran MI
    . Aerobic fitness among Caucasian, African-American, and Latino youth. Ethn Dis. 2006; 16(1): 120–125
    OpenUrlPubMed
  88. 88.↵
    1. Lee NE,
    2. De AK,
    3. Simon PA
    . School-based physical fitness testing identifies large disparities in childhood overweight in Los Angeles. J Am Diet Assoc. 2006; 106(1): 118–121
    OpenUrlCrossRefPubMed
  89. 89.↵
    1. Goodman E,
    2. Daniels SR,
    3. Dolan LM
    . Socioeconomic disparities in insulin resistance: results from the Princeton School District Study. Psychosom Med. 2007; 69(1): 61–67
    OpenUrlAbstract/FREE Full Text
  90. 90.↵
    1. Delva J,
    2. O'Malley PM,
    3. Johnston LD
    . Racial/ethnic and socioeconomic status differences in overweight and health-related behaviors among American students: national trends 1986–2003. J Adolesc Health. 2006; 39(4): 536–545
    OpenUrlCrossRefPubMed
  91. 91.↵
    1. Neumark-Sztainer D,
    2. Story M,
    3. Hannan PJ,
    4. Croll J
    . Overweight status and eating patterns among adolescents: where do youths stand in comparison with the Healthy People 2010 objectives?Am J Public Health. 2002; 92(5): 844–851
    OpenUrlCrossRefPubMed
  92. 92.↵
    1. Davy BM,
    2. Harrell K,
    3. Stewart J,
    4. King DS
    . Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi. South Med J. 2004; 97(12): 571–577
    OpenUrlCrossRefPubMed
  93. 93.↵
    1. Hedley AA,
    2. Ogden CL,
    3. Johnson CL,
    4. Carroll MD,
    5. Curtin LR,
    6. Flegal KM
    . Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA. 2004; 291(23): 2847–2850
    OpenUrlCrossRefPubMed
  94. 94.↵
    1. Beets MW,
    2. Pitetti KH
    . One-mile run/walk and body mass index of an ethnically diverse sample of youth. Med Sci Sports Exerc. 2004; 36(10): 1796–1803
    OpenUrlCrossRefPubMed
  95. 95.↵
    1. Ganz ML,
    2. Xuan Z,
    3. Hunter DG
    . Prevalence and correlates of children's diagnosed eye and vision conditions. Ophthalmology. 2006; 113(12): 2298–2306
    OpenUrlCrossRefPubMed
  96. 96.↵
    1. Slover J,
    2. Gibson J,
    3. Tosteson T,
    4. Smith B,
    5. Koval K
    . Racial and economic disparity and the treatment of pediatric fractures. J Pediatr Orthop. 2005; 25(6): 717–721
    OpenUrlCrossRefPubMed
  97. 97.↵
    1. Hambidge SJ,
    2. Emsermann CB,
    3. Federico S,
    4. Steiner JF
    . Disparities in pediatric preventive care in the United States, 1993–2002. Arch Pediatr Adolesc Med. 2007; 161(1): 30–36
    OpenUrlCrossRefPubMed
  98. 98.↵
    1. Selden TM
    . Compliance with well-child visit recommendations: evidence from the Medical Expenditure Panel Survey, 2000–2002. Pediatrics. 2006; 118(6). Available at: www.pediatrics.org/cgi/content/full/118/6/e1766
  99. 99.↵
    1. Milazzo AS Jr.,
    2. Sanders SP,
    3. Armstrong BE,
    4. Li JS
    . Racial and geographic disparities in timing of bidirectional Glenn and Fontan stages of single-ventricle palliation. J Natl Med Assoc. 2002; 94(10): 873–878
    OpenUrlPubMed
  100. 100.↵
    1. Stevens GD,
    2. Shi L
    . Effect of managed care on children's relationships with their primary care physicians: differences by race. Arch Pediatr Adolesc Med. 2002; 156(4): 369–377
    OpenUrlPubMed
  101. 101.↵
    1. Weech-Maldonado R,
    2. Morales LS,
    3. Spritzer K,
    4. Elliott M,
    5. Hays RD
    . Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care. Health Serv Res. 2001; 36(3): 575–594
    OpenUrlPubMed
  102. 102.↵
    1. Seid M,
    2. Stevens GD,
    3. Varni JW
    . Parents' perceptions of pediatric primary care quality: effects of race/ethnicity, language, and access. Health Serv Res. 2003; 38(4): 1009–1031
    OpenUrlCrossRefPubMed
  103. 103.↵
    1. Inkelas M,
    2. Smith KA,
    3. Kuo AA,
    4. Rudolph L,
    5. Igdaloff S
    . Health care access for children with special health care needs in California. Matern Child Health J. 2005; 9(2 suppl): S109–S116
    OpenUrlCrossRefPubMed
  104. 104.↵
    1. Newacheck PW,
    2. Hung YY,
    3. Wright KK
    . Racial and ethnic disparities in access to care for children with special health care needs. Ambul Pediatr. 2002; 2(4): 247–254
    OpenUrlCrossRefPubMed
  105. 105.↵
    1. van Dyck PC,
    2. Kogan MD,
    3. McPherson MG,
    4. Weissman GR,
    5. Newacheck PW
    . Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med. 2004; 158(9): 884–890
    OpenUrlCrossRefPubMed
  106. 106.↵
    1. Ngui EM,
    2. Flores G
    . Satisfaction with care and ease of using health care services among parents of children with special health care needs: the roles of race/ethnicity, insurance, language, and adequacy of family-centered care. Pediatrics. 2006; 117(4): 1184–1196
    OpenUrlAbstract/FREE Full Text
  107. 107.↵
    1. Kokoska ER,
    2. Bird TM,
    3. Robbins JM,
    4. Smith SD,
    5. Corsi JM,
    6. Campbell BT
    . Racial disparities in the management of pediatric appendicitis. J Surg Res. 2007; 137(1): 83–88
    OpenUrlCrossRefPubMed
  108. 108.↵
    1. Omoloja A,
    2. Stolfi A,
    3. Mitsnefes M
    . Racial differences in pediatric renal transplantation: 24-year single center experience. J Natl Med Assoc. 2006; 98(2): 154–157
    OpenUrlPubMed
  109. 109.↵
    1. Mahle WT,
    2. Kanter KR,
    3. Vincent RN
    . Disparities in outcome for black patients after pediatric heart transplantation. J Pediatr. 2005; 147(6): 739–743
    OpenUrlCrossRefPubMed
  110. 110.↵
    1. Tai-Seale M,
    2. Freund D,
    3. LoSasso A
    . Racial disparities in service use among Medicaid beneficiaries after mandatory enrollment in managed care: a difference-in-differences approach. Inquiry. 2001; 38(1): 49–59
    OpenUrlPubMed
  111. 111.↵
    1. Patterson PD,
    2. Baxley EG,
    3. Probst JC,
    4. Hussey JR,
    5. Moore CG
    . Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years. Matern Child Health J. 2006; 10(6): 527–536
    OpenUrlCrossRefPubMed
  112. 112.↵
    1. Flores G,
    2. Bauchner H,
    3. Feinstein AR,
    4. Nguyen UDT
    . The impact of ethnicity, family income, and parental education on children's health and use of health services. Am J Public Health. 1999; 89(7): 1066–1071
    OpenUrlCrossRefPubMed
  113. 113.↵
    1. Washington EL,
    2. Shen JJ,
    3. Bell R,
    4. Coleman C,
    5. Shi L
    . Patterns of hospital-based pediatric care across diverse ethnicities: the case of pneumonia. J Health Care Poor Underserved. 2004; 15(3): 462–473
    OpenUrlCrossRefPubMed
  114. 114.↵
    1. Buescher PA,
    2. Horton SJ,
    3. Devaney BL,
    4. et al
    . Differences in use of health services between white and African American children enrolled in Medicaid in North Carolina. Matern Child Health J. 2003; 7(1): 45–52
    OpenUrlCrossRefPubMed
  115. 115.↵
    1. Untalan F,
    2. Woodruff K,
    3. Hardy C,
    4. Liao M,
    5. Krupitsky D
    . Disparities in outcomes for pediatric cancer patients treated in Hawai'i: comparing Hawai'i residents to children referred from the Pacific Islands. Pac Health Dialog. 2004; 11(2): 114–119
    OpenUrlPubMed
  116. 116.↵
    1. Allen ML,
    2. Elliott MN,
    3. Morales LS,
    4. Diamant AL,
    5. Hambarsoomian K,
    6. Schuster MA
    . Adolescent participation in preventive health behaviors, physical activity, and nutrition: differences across immigrant generations for Asians and Latinos compared with whites. Am J Public Health. 2007; 97(2): 337–343
    OpenUrlCrossRefPubMed
  117. 117.↵
    1. Wenceslao S,
    2. Gotay CC,
    3. Cheung LW,
    4. White K
    . Patterns of childhood cancer in Hawai'i between 1975 and 2000. Hawaii Med J. 2006; 65(8): 221–225
    OpenUrlPubMed
  118. 118.↵
    1. Buechner JS
    . Health disparities among racial and ethnic groups in Rhode Island. Med Health R I. 2000; 83(8): 257–258
    OpenUrlPubMed
  119. 119.↵
    1. Stevens GD,
    2. Shi L
    . Racial and ethnic disparities in the quality of primary care for children. J Fam Pract. 2002; 51(6): 573
    OpenUrlPubMed
  120. 120.↵
    1. Stevens GD,
    2. Shi L,
    3. Cooper LA
    . Patient-provider racial and ethnic concordance and parent reports of the primary care experiences of children. Ann Fam Med. 2003; 1(2): 105–112
    OpenUrlAbstract/FREE Full Text
  121. 121.↵
    1. Borders TF,
    2. Brannon-Goedeke A,
    3. Arif A,
    4. Xu KT
    . Parents' reports of children's medical care access: are there Mexican-American versus non-Hispanic white disparities?Med Care. 2004; 42(9): 884–892
    OpenUrlCrossRefPubMed
  122. 122.↵
    1. Brousseau DC,
    2. Hoffmann RG,
    3. Yauck J,
    4. Nattinger AB,
    5. Flores G
    . Disparities for Latino children in the timely receipt of medical care. Ambul Pediatr. 2005; 5(6): 319–325
    OpenUrlCrossRefPubMed
  123. 123.↵
    1. Beckmann KR,
    2. Melzer-Lange MD,
    3. Gorelick MH
    . Emergency department management of sexually transmitted infections in US adolescents: results from the National Hospital Ambulatory Medical Care Survey. Ann Emerg Med. 2004; 43(3): 333–338
    OpenUrlCrossRefPubMed
  124. 124.↵
    1. Claudio L,
    2. Stingone JA,
    3. Godbold J
    . Prevalence of childhood asthma in urban communities: the impact of ethnicity and income. Ann Epidemiol. 2006; 16(5): 332–340
    OpenUrlCrossRefPubMed
  125. 125.↵
    1. Akinbami LJ,
    2. Rhodes JC,
    3. Lara M
    . Racial and ethnic differences in asthma diagnosis among children who wheeze. Pediatrics. 2005; 115(5): 1254–1260
    OpenUrlAbstract/FREE Full Text
  126. 126.↵
    1. Deck D,
    2. Ley KV
    . Medicaid eligibility and access to mental health services among adolescents in substance abuse treatment. Psychiatr Serv. 2006; 57(2): 263–265
    OpenUrlCrossRefPubMed
  127. 127.↵
    1. Kataoka SH,
    2. Zhang L,
    3. Wells KB
    . Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status. Am J Psychiatry. 2002; 159(9): 1548–1555
    OpenUrlCrossRefPubMed
  128. 128.↵
    1. Richardson LP,
    2. DiGiuseppe D,
    3. Garrison M,
    4. Christakis DA
    . Depression in Medicaid-covered youth: differences by race and ethnicity. Arch Pediatr Adolesc Med. 2003; 157(10): 984–989
    OpenUrlCrossRefPubMed
  129. 129.↵
    1. Sturm R,
    2. Ringel JS,
    3. Andreyeva T
    . Geographic disparities in children's mental health care. Pediatrics. 2003; 112(4). Available at: www.pediatrics.org/cgi/content/full/112/4/e308
  130. 130.↵
    1. Stevens J,
    2. Harman JS,
    3. Kelleher KJ
    . Ethnic and regional differences in primary care visits for attention-deficit hyperactivity disorder. J Dev Behav Pediatr. 2004; 25(5): 318–325
    OpenUrlCrossRefPubMed
  131. 131.↵
    1. Quintana J,
    2. Goldmann D,
    3. Homer C
    . Social disparities in the use of diagnostic tests for children with gastroenteritis. Int J Qual Health Care. 1997; 9(6): 419–425
    OpenUrlAbstract/FREE Full Text
  132. 132.↵
    1. Xu KT,
    2. Borders TF,
    3. Arif AA
    . Ethnic differences in parents' perception of participatory decision-making style of their children's physicians. Med Care. 2004; 42(4): 328–335
    OpenUrlCrossRefPubMed
  133. 133.↵
    1. Yu SM,
    2. Nyman RM,
    3. Kogan MD,
    4. Huang ZJ,
    5. Schwalberg RH
    . Parent's language of interview and access to care for children with special health care needs. Ambul Pediatr. 2004; 4(2): 181–187
    OpenUrlCrossRefPubMed
  134. 134.↵
    1. Grossman DC,
    2. Krieger JW,
    3. Sugarman JR,
    4. Forquera RA
    . Health status of urban American Indians and Alaska Natives: a population-based study. JAMA. 1994; 271(11): 845–850
    OpenUrlCrossRefPubMed
  135. 135.↵
    1. Frenn M,
    2. Malin S,
    3. Bansal N,
    4. et al
    . Addressing health disparities in middle school students' nutrition and exercise. J Community Health Nurs. 2003; 20(1): 1–14
    OpenUrlCrossRefPubMed
  136. 136.↵
    1. Szilagyi PG,
    2. Schaffer S,
    3. Shone L,
    4. et al
    . Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics. 2002; 110(5). Available at: www.pediatrics.org/cgi/content/full/110/5/e58
Back to top

In this issue

Pediatrics
Vol. 125, Issue 4
1 Apr 2010
View this article with LENS
Email Article
Request Permissions
Article Alerts
Citation Tools
Racial and Ethnic Disparities in the Health and Health Care of Children
Glenn Flores, THE COMMITTEE ON PEDIATRIC RESEARCH
Pediatrics Apr 2010, 125 (4) e979-e1020; DOI: 10.1542/peds.2010-0188
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
Print
Download PDF
Insight Alerts

Jump to section

Related Articles

Cited By...

More in this TOC Section

Similar Articles

Subjects