Racial and Ethnic Disparities in the Health and Health Care of Children
- Glenn Flores, MD,
- THE COMMITTEE ON PEDIATRIC RESEARCH
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.
- health care disparities
- ethnic groups
- Hispanic Americans
- African Americans
- Asian Americans
- North American
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.
“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
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.
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
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
The vast majority of articles (94 of 109 [86%]) addressed disparities in AA children (Table 1).
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).
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.
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.
There were 24 articles (24 of 109 [22%]) that addressed disparities in API children (Table 2).
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).
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.
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.
There were 66 articles (67 of 109 [61%]) that addressed disparities in Latino children (Table 3).
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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
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
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
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
William L. Cull, PhD
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
- Copyright © 2010 by the American Academy of Pediatrics