Technical Report—Racial and Ethnic Disparities inthe Health and Health Care of Children
abstractOBJECTIVE: This technical report reviews and synthesizes the pub-lished literature on racial/ethnic disparities in children’s health andhealth care.
METHODS: A systematic review of the literature was conducted forarticles published between 1950 and March 2007. Inclusion criteriawere peer-reviewed, original research articles in English on racial/ethnic disparities in the health and health care of US children. Searchterms used included “child,” “disparities,” and the Index Medicusterms for each racial/ethnic minority group.
RESULTS: Of 781 articles initially reviewed, 111 met inclusion criteriaand constituted the final database. Review of the literature revealedthat racial/ethnic disparities in children’s health and health care arequite extensive, pervasive, and persistent. Disparities were notedacross the spectrum of health and health care, including in mortalityrates, access to care and use of services, prevention and populationhealth, health status, adolescent health, chronic diseases, specialhealth care needs, quality of care, and organ transplantation.Mortality-rate disparities were noted for children in all 4 major USracial/ethnic minority groups, including substantially greater risksthan white children of all-cause mortality; death from drowning, fromacute lymphoblastic leukemia, and after congenital heart defect sur-gery; and an earlier median age at death for those with Down syn-drome and congenital heart defects. Certain methodologic flaws werecommonly observed among excluded studies, including failure to eval-uate children separately from adults (22%), combining all nonwhitechildren into 1 group (9%), and failure to provide a white comparisongroup (8%). Among studies in the final database, 22% did not performmultivariable or stratified analyses to ensure that disparities per-sisted after adjustment for potential confounders.
CONCLUSIONS: Racial/ethnic disparities in children’s health andhealth care are extensive, pervasive, and persistent, and occur acrossthe spectrum of health and health care. Methodologic flaws were iden-tified in how such disparities are sometimes documented and analyzed.Optimal health and health care for all children will require recognition ofdisparities as pervasive problems, methodologically sound disparitiesstudies, and rigorous evaluation of disparities interventions. Pediatrics2010;125:e979–e1020
Glenn Flores, MD, THE COMMITTEE ON PEDIATRIC RESEARCH
KEY WORDShealth care disparities, ethnic groups, Hispanic Americans,African Americans, Asian Americans, Indians, North American
ABBREVIATIONSCDC—Centers for Disease Control and PreventionCI—confidence intervalAAP—American Academy of PediatricsAA—African AmericanAPI—Asian/Pacific IslanderAI/AN—American Indian/Alaska NativeALL—acute lymphoblastic leukemiaED—emergency departmentSCHIP—State Children’s Health Insurance ProgramADHD—attention-deficit/hyperactivity disorderSES—socioeconomic status
This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.
The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.
www.pediatrics.org/cgi/doi/10.1542/peds.2010-0188
doi:10.1542/peds.2010-0188
All technical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.
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INTRODUCTION
Racial/ethnic disparities in health andhealth care recently have receivedconsiderable attention. The Agency forHealthcare Research and Quality hasissued an annual national health caredisparities report since 2003.1,2 Reduc-tion and elimination of disparities isone of the major goals of Healthy Peo-ple 2010,3 part of the strategic plan ofthe Eunice Kennedy Shriver National In-stitute of Child Health and Human De-velopment,4 and part of the strategicimperatives of the Centers for DiseaseControl and Prevention (CDC).5 A sepa-rate National Institutes of Health cen-ter devoted to minority health andhealth disparities (the National Centerfor Minority Health and Health Dispar-ities) was founded in 2000.6 The Insti-tute of Medicine released a land-mark monograph on disparities,7
and a federal bipartisan bill target-ing health care disparities recentlywas introduced.8
Little attention has been paid, how-ever, to racial/ethnic disparities in thehealth and health care of children. Forexample, only 5 of 103 studies in theInstitute of Medicine’s extensive re-view of the literature on health caredisparities specifically addressed ra-cial/ethnic disparities in children’shealth care.7 The purpose of this tech-nical report, therefore, is to reviewand synthesize the published litera-ture on racial/ethnic disparities inchildren’s health and health care. Thereport begins with definitions of keyterms and an overview of sociodemo-graphic trends in minority children.Specific minority groups, the impor-tance of racial/ethnic subgroups, stud-ies of interventions to reduce racial/ethnic disparities, and methodologicissues are then reviewed.
DEFINITIONS
“Race/ethnicity” is defined as thechild’s racial or ethnic group (includ-
ing “multiracial”), as designated bythe parent and/or child. “Minority”will be the term used for children ofnonwhite race/ethnicity. Althoughmul-tiple definitions have been proposedfor the term “disparities,” the HealthResources and Services Administra-tion definition of disparities was used,whichdefinesdisparities as “population-specific differences in the presenceof disease, health outcomes, or accessto care.”9
METHODS
Only statistically significant disparitiesare reported herein (ie, those with ei-ther a P value of less than .05 or 95%confidence intervals [CIs] that are non-overlapping with non-Latino white chil-dren). The only exception to this rulewas inclusion of certain crude out-come rates in large population-basedsamples in which the differences wereconsidered quantitatively or clinicallysignificant (ie, when there was at leasta 50% difference in rates between aspecific racial/ethnic minority groupand the white population). Only studiesthat examined racial/ethnic dispari-ties in the context of comparisons towhite children were included in the lit-erature review. Notation was made ofwhether disparities included adjust-ment for relevant covariates. When ap-propriate data were available, seculartrends for specific disparities are de-scribed. Unless otherwise noted, thereference group for any racial/ethnicdisparity is non-Latino white children.
LITERATURE SEARCH
The scope of published literature onracial/ethnic disparities is broad. Inaddition, although racial/ethnic dis-parities in neonatal and infant mor-tality rates10 and dental care11 havebeen fairly well described, relativelylittle has been published on racial/ethnic disparities in children and ado-lescents. The terms that have beenused to describe disparities also have
been neither standardized nor consis-tent. As a consequence, the literaturesearch was limited to only those stud-ies that specifically examined racial/ethnic disparities for US children andadolescents, to ensure a focus on dis-parities and a body of literature in ur-gent need of a systematic review. Thus,articles on racial/ethnic disparities inneonatal and infant mortality and den-tal care were excluded, because dis-parities in these domains have com-paratively been more well described,and articles on pediatric workforce di-versity, an area that was addressed ina recent American Academy of Pediat-rics (AAP) policy statement,12 alsowere excluded.
The database used for the literaturesearch was Ovid Medline; the searchencompassed the years 1950 throughthe first week of March 2007. The initialsearch strategy included the terms“child” and “disparities” (both as med-ical subject heading terms and keywords), which yielded 666 citations. Toensure that no relevant citations weremissed, individual searches also wereperformed by using “disparities,”“child,” and Index Medicus terms foreach racial/ethnic minority group,which yielded the following children’sdisparities references: “African conti-nental ancestry group,” n� 35; “Asiancontinental 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 theconsistency and reproducibility of thisliterature search, additional second-ary references were not included fromthe citation lists of the primary articlesincluded in the database.
Abstracts for all 781 articles were re-viewed. Because the focus of the liter-ature review was original, peer-reviewed articles in English on racial/ethnic disparities in the health and
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health care of US children, review arti-cles, editorials, commentaries, per-spective pieces, theoretical or concep-tual pieces, transcripts of speeches,letters to the editor, dental care arti-cles, articles that addressed adults orthe elderly, articles without analysis ofracial/ethnic disparities, articles onneonatal or infant mortality issues, ar-ticles on workforce diversity, articlesthat did not examine disparities in thehealth of US children, and duplicate ci-tations were excluded. Application ofthese exclusion criteria yielded 227 ar-ticles. The full print versions of theseremaining 227 articles were reviewed,and reapplication of the exclusion cri-teria yielded a final database of 111articles, 2 of which examined interven-tions aimed at reducing racial/ethnicdisparities (and were consideredseparately).
SOCIODEMOGRAPHICS OFMINORITY CHILDREN IN THEUNITED STATES
The United States is experiencing a de-mographic surge in minority children(Fig 1). There are 31.4 million children(younger than 18 years old) of non-white race/ethnicity in the UnitedStates,13 comprising 43% of children,and representing an 11% increase
since 200014 and a 58% increase since1990.15 Since 2000,minorities have rep-resented more than half of the popula-tion of the nation’s 100 largest cities,and 42 of the 100 largest US cities are“minority majority” (defined as popu-lations in which racial/ethnic minori-ties outnumber the white popula-tion).16 In California, the largest statein the nation, minorities have outnum-bered whites since 2000, and currentlyrepresent 57% of the state’s popula-tion.17,18 Conservative estimates indi-cate that minorities will constitute halfof US children by 2040.19
Latinos are the largest and fastest-growing minority group of US children(Fig 1), representing 20% of children inAmerica (equivalent to 15 million).13,20
African Americans (AAs) are thesecond-largest minority group of USchildren, representing 15% of childrenin America (equivalent to 10.9 mil-lion)13; between 1990 and 2006, theirpopulation proportion slightly de-creased. Asians/Pacific Islanders(APIs) are the third-largest minoritygroup of US children, representing 4%of children in America (equivalent to 3million)13; between 2000 and 2006,their population proportion grew by14% (1990 US Census data are not
available on API children). American In-dians/Alaska Natives (AIs/ANs) repre-sent 1% of children in America (equiv-alent to �661 000)13; between 1990and 2006, their population proportiondecreased by 18%. The number of mul-tiracial children in the United States(ie, self-designated by the caregiver asbelonging to 2 or more races) in 2006was 2.9 million, representing 4% of theUS population of children,13 a propor-tion that has not changed since 1990.
HEALTH AND HEALTH CAREDISPARITIES IN SPECIFIC RACIAL/ETHNIC GROUPS OF CHILDREN
African Americans
The vast majority of articles (94 of 109[86%]) addressed disparities in AAchildren (Table 1).
Mortality
Eight articles documented AA/whitedisparities in mortality rates. Overallchildhood mortality rates were foundto be consistently higher for AA chil-dren; national data for a 43-year pe-riod revealed marked crude mortality-rate disparities in young children 1 to 4years of age (twice that of white chil-dren) and older children 5 to 14 yearsof age and increases in the mortality-disparity ratio in the most recent 10-year period. Two other studies thatadjusted for relevant covariates docu-mented significantly higher mortalityrates for AA children versus white chil-dren in the Detroit tri-county area forboys and older girls (10–19 years old)and among children without congeni-tal anomalies in the state of Michigan.AA children also experience higherrisks of death from drowning in aswimming pool, especially in publicpools, with the drowning rate in hotel/motel pools disproportionately higher.Significant disease-specific mortality-rate disparities were identified foracute lymphoblastic leukemia (ALL),median age at death for Down syn-
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13.9
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-16.8
58.5
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-30
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-10
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10
20
30
40
50
60
70
80
90
% o
f p
op
ula
tion
1990 Census2006 ACSInterval increase
Nonwhite
White(non-Latino) Latino
AA API
AI/ANMultiracial
FIGURE 1Growth of racial/ethnic minority population of US children between 1990 and 2006. ACS indicatesAmerican Community Survey. Data were unavailable for APIs for the 1990 US Census, so data depictedare from the 2000 US Census.
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drome, congenital heart defects (bothin terms of the fatality rate and a loweraverage age at death), and in-hospitaldeath after congenital heart surgery.
Access to Care and Use of Services
Multiple noteworthy disparities weredocumented in access to health careand use of health services (Table 1).Disparities in access to care includehigher rates than those of white chil-dren of unmet health care needs,lower rates of access to primary careproviders (including race being morestrongly associated with this outcomethan income), a higher likelihood ofhaving no usual source of care,greater odds of not being referred to aspecialist by the health care provider,higher hospitalization rates for ambu-latory care–sensitive conditions, andhigher odds of appendicitis rupture(considered an access indicator, be-cause it indicates failed access totimely, appropriate care early in thecourse of appendicitis). Disparities inthe use of health services includelower physician-visit rates and higherodds of going 1 year or longer from thelast physician visit, a higher rate ofemergency department (ED) visits,greater likelihood of medically unnec-essary Emergency Medical Servicestransports, fewer calls to physicians’offices, and, among those with Medic-aid coverage, lower odds of well-childcare and diagnosis and treatment forvarious pediatric conditions, andlower expenditures for outpatient andED care and for prescriptions.
Prevention and Population Health
Disparities were identified in breast-feeding, immunization rates, injuries,obesity, physical activity, and nutrition(Table 1). Breastfeeding is significantlyless likely among AA versus white in-fants, whethermeasured by ever beingbreastfed, the proportion exclusivelybreastfed, or the proportion receivingany human milk. AA children have theTA
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lowest immunization rates for the pri-mary immunization series and havesubstantially greater delays and alater mean age for multiple immuniza-tion categories and doses. They have asubstantially higher firearm injuryrate and, as young children, havehigher odds of living in householdswithout stair gates, cabinet safetylatches or locks, or hot-water thermo-stat settings that have been turneddown.
Studies consistently document higherrates of obesity and overweight in AAchildren (Table 1). One study also re-vealed selection of larger body sizewhen asked to identify ideal adult bodysize; less personal, family, and peerconcern about weight; and fewer chil-dren trying to lose weight. Disparitiesalso have been identified in lower aer-obic fitness levels, slower 1-mile run/walk time, lower likelihood of vigorousexercise in females, and higher num-bers of television-viewing hours. Nutri-tional disparities include a higher like-lihood of consuming more calories asfat and saturated fat, lower mean con-sumption of fiber and calcium, andlower likelihood of eating breakfastregularly.
Adolescent Health Issues
AA female adolescents have higherrisks versus white female adolescentsof skipping breakfast, being obese,lacking health insurance, needing butnot getting medical care, having anysexually transmitted disease, perpe-trating violence, and being a victim ofviolence (Table 1). Several studieshave also documented live birth ratesthat are 2 to 5 times higher than forwhite female adolescents, and the dis-parity ratio has worsened over time.AA female adolescents also havegreater adjusted odds of alcohol test-ing when seen in the ED for traumaticinjury and are particularly at high riskof underusing substance abuse ser-
vices. Male AA adolescents have ahigher risk of perpetrating violenceand being a victim of violence. For AAadolescents of both genders, higherrisks were identified for underuse ofsubstance abuse services, older age atfirst use of substance abuse services,and suboptimal health status andlower use of physicians’ offices as theusual source of care among those re-cently enrolled in a State Children’sHealth Insurance Program (SCHIP).
Health Status
Multiple studies have documentedhealth-status disparities for AA chil-dren, whether analyzing global healthstatus or the prevalence of specificconditions (Table 1). Three studies re-vealed that AA children have higher ad-justed odds of fair or poor health andlower odds of excellent or very goodhealth. Higher rates of activity limita-tions, school limitations, and globalstress also were noted. Significantlyhigher crude rates than in white chil-dren have been seen for all stroke cat-egories (both hemorrhagic and isch-emic), invasive pneumococcal disease,and tuberculosis. HIV/AIDS disparitiesare substantial, and include the larg-est percentages and numbers of newdiagnoses in every age group of chil-dren and adolescents and via perinataltransmission, as well as longer ad-justed lengths of stay for those whoare hospitalized.
Asthma, Mental Health Care, andSpecial Health Care Needs
A particularly extensive body of litera-ture is available on disparities for 3specific issues: asthma, mental healthcare (including behavioral and devel-opmental issues), and special healthcare needs (Table 1).
Several studies have documented thatAA children have the highest asthmaprevalence of any racial/ethnic group,and this prevalence is substantiallyhigher than that for white children
(Table 1). Secular-trend data indicatethat this disparity has widened overtime. Compared with white children,AA children also experience substan-tially higher rates of asthma mortality,hospitalizations, ED visits, and officevisits, and the disparities in asthmamortality and hospitalizations havewidened over time. Additional asthmadisparities include higher attack prev-alence; lower rates of filled prescrip-tions; higher potential disease burden(diagnosed plus possible but undiag-nosed disease); worse asthma physicalhealth scores; lower odds of use of �2-agonists, inhaled steroids, anddaily anti-inflammatory medication; and higherodds of sensitivities to cockroach, dustmite, and mold allergens.
Several key disparities were noted inmental health care and behavioral/de-velopmental disorders. Most study re-sults have indicated lower use of men-tal health services, including loweradjusted odds of any mental healthservice use, outpatient service use, in-formal service use (such as self-helpand peer counseling), receiving treat-ment for depression from mentalhealth specialists, and receipt of psy-chotropic, stimulant, antidepressant,or neuroleptic medications (Table 1).One study, however, found higher oddsof use of state-funded mental healthservices in New York City. Higher ad-justed odds of developmental delayshave been noted, but underdiagnosis,undertreatment, and other disparitiesfor attention-deficit/hyperactivity dis-order (ADHD)were found in other stud-ies, including lower adjusted odds ofevaluation, receiving a diagnosis, andreceiving medication or treatment,and higher proportions of parentswith negative expectations abouttreatment helpfulness. AA childrenalso were found to receive a diagnosisof autism 1.4 years later than whitechildren and to be in mental healthtreatment an average of 13 months
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longer than white children before re-ceiving the autism diagnosis.
National data reveal several dispari-ties for AA children with special healthcare needs (Table 1), including higherodds of having no regular health careprovider, averaging fewer physicianvisits, being dissatisfied with care, en-countering problems with ease of useof services, and not receiving ade-quate time and information from chil-dren’s health care providers.
Quality
Numerous disparities were identifiedin quality of care (Table 1). Lower ad-justed odds versus white childrenwere noted for meeting the recom-mended number of well-child visitsand receiving any counseling orscreening during well-child visits.Lower adjusted scores were observedfor timeliness of care, health insur-ance plan service, getting neededmed-ical care, primary care comprehen-siveness, primary care providerstrength of affiliation, and primarycare provider interpersonal relation-ships. Greater adjusted odds werefound for the child being assigned tothe health care provider; the providernever/only sometimes understandinghow the parent prefers to rear thechild; and the provider discussing vio-lence in the community, smoking in thehousehold, using alcohol or drugs inhousehold, trouble paying for child’sneeds, and spouse/partner support ofparenting efforts.
Among those with end-stage renal dis-ease, AA children are substantially lesslikely than white children to be acti-vated on the kidney transplant waitinglist but are significantly more likely toreceive hemodialysis rather than peri-toneal dialysis and to receive an inad-equate hemodialysis dose. AA childrenhave lower odds than white children ofbeing diagnosed with any eye or visioncondition, are more likely to undergo
closed reduction with internal fixationof supracondylar humerus fractures,undergo bidirectional Glenn and Fon-tan procedures at significantly olderages among those with cardiovasculardisease, and have longer time to oper-ation and lengths of stay, higher hospi-tal charges, higher odds of perforationand other complications, and lowersodds of laparoscopic proceduresamong those with appendicitis. AA pa-tients who have a heart transplanthave double the odds of graft failure,lower graft survival rates, a mediangraft survival time that is 6 yearslower, a median age at heart trans-plant that is 5 years greater, and ahigher likelihood of HLA mismatch. AAchildren are less likely to receive pre-emptive kidney transplants, and theyreceive fewer living transplants andmore cadaveric transplants.
Asians/Pacific Islanders
There were 24 articles (24 of 109[22%]) that addressed disparities inAPI children (Table 2).
Mortality
Only 1 study (Table 2) examined mor-tality among APIs; it revealed that na-tive Hawaiian children have a highercrude mortality rate than that of whitechildren.
Access to Care and Use of Services
Several studies found disparities forAPI versus white children in access tohealth care and use of health services(Table 2). API children have greater ad-justed odds of having no usual sourceof care, having made no visit to a phy-sician or other health care provider inthe past year, and going more than 1year since the last physician visit, aswell as a lower adjusted number ofphysician visits in the past year.Higher adjusted odds of appendicitisrupture also were noted. Among chil-dren with cancer, Pacific Islandershad significantly greater odds of
death, untimely treatment, not com-pleting 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 Minne-sota revealed triple the crude firearminjury rate of that in white children. APIchildren were found to have the high-est proportion of elevated blood leadconcentrations in the state of RhodeIsland and are the only racial/ethnicgroup whose rate increased over time.Higher adjusted odds of overweightoccur among Pacific Islander, Filipino,and Asian children, and slower ad-justed 1-mile run/walk times werenoted for most age groups of API chil-dren. API children also have a lowercalcium intake—the lowest of anyracial/ethnic group.
Adolescent Health Issues
Compared with white adolescents, APIadolescents were found to have loweradjusted odds of seatbelt use, sun-screen use, and weekly physical activ-ity and greater adjusted daily hoursof television/video-game screen time(Table 2).
Health Status
APIs have a higher adjusted likelihoodthan that of whites to have fair or poorhealth status (Table 2). Data from thestate of Hawaii revealed that Filipinoand Chinese boys have the highestrates of leukemia, and Chinese boyshave the highest ALL rate.
Mental Health Care
API children have been found to havelower adjusted odds of any mentalhealth service use, outpatient mentalhealth service use, and 24-hour-careservice use (ie, inpatient, residential,group-home, or alcohol/drug abusetreatment) (Table 2). New York Citydata, however, indicate higher ad-
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justed odds of use of state-fundedmental health services.
Quality
Several studies have documented APIdisparities in primary care quality, in-cluding lower overall quality of pri-mary care scores, lower primary careprovider interpersonal relationshipscores, and lower scores for specificprimary care services available to thechild (Table 2). Lower adjusted pri-mary care quality scores have beenfound for 4 elements of care among APIparents interviewed in English and 6elements of care among API parentsfor whom the primary language spo-ken at home is not English. Amongthose hospitalized for pneumonia, APIchildren have lower adjusted odds ofbronchoscopy and mechanical ventila-tion, a longer adjusted length of stay,and higher adjusted charges.
Latinos
There were 66 articles (67 of 109[61%]) that addressed disparities inLatino children (Table 3).
Mortality
Puerto Rican children 1 to 4 years ofage were found to have a higher crudemortality rate than their white coun-terparts (Table 3). A higher drowningrate in neighborhood pools for Latinosalso was found, along with higherswimming pool drowning rates in gen-eral for Latino male adolescents.Higher adjusted risks of death existamong Latinos (versus whites) withALL and after congenital heart surgery.
Access to Care and Use of Services
Multiple studies have documented awide range of disparities in access tocare and use of services for Latino chil-dren (Table 3). In comparison withwhite children, Latino children havegreater adjusted odds of being unin-sured, having no usual source of careor health care provider, having made
no physician visit in the past year, hav-ing gone 1 year or more since the lastphysician visit, making fewer physi-cian visits in the past year, makingfewer calls to physicians’ offices, notbeing referred to a specialist, having aperforated appendicitis, and never oronly sometimes getting medical carewithout long waits, getting timely rou-tine care or telephone help, and get-ting brief wait times for medical ap-pointments. Similar findings werenoted in studies that focused on Lati-nos before or at the time of enrollmentin SCHIP and amongMexican Americanchildren.
Prevention and Population Health
Disparities were identified in breast-feeding, injuries, obesity, physical ac-tivity, and nutrition (Table 3). Com-pared with white infants, a lowercrude proportion of Mexican-Americaninfants are ever breastfed. Latinohouseholds with children 4 to 35months of age have lower adjustedodds than do white households of put-ting up stair gates. Multiple studieshave documented significantly higheradjusted odds of overweight and obe-sity, including 2 studies that showedthat Latinos have the highest adjustedrates of overweight and obesity of anyracial/ethnic group. Physical-activitydisparities included lower adjustedaerobic fitness, slower 1-mile run/walk times, higher average number oftelevision-viewing hours on the aver-age weekday, and lower regular vigor-ous physical activity among females.Lower calcium intake has been noted,as has as a higher likelihood of con-sumption of more than 10% of caloriesas saturated fat.
Adolescent Health Issues
Latina adolescents have a higher riskthan do white adolescents of not hav-ing health insurance, perpetrating vio-lence, and being a victim of violence.Disparities for male adolescents in-
clude a higher risk of no health insur-ance, going more than 2 years sincethe last physical examination, and be-ing a victim of violence (Table 3). Latinoadolescents recently enrolled in SCHIPhave a higher crude likelihood of fairor poor health and are less likely touse physician’s offices as their usualsource of care. Latina adolescents 15to 19 years of age have a crude birthrate 3 times higher than their whitecounterparts and the highest of any ra-cial/ethnic group. Latino adolescentshave a lower adjusted odds of beingtreated in the ED for sexually transmit-ted diseases, but male Latino adoles-cents with traumatic injuries have ahigher adjusted odds of alcohol testingin the ED. Latino adolescents also havelower adjusted odds of bicycle helmetand sunscreen use.
Health Status
National data reveal a higher adjustedlikelihood of fair or poor health in Lati-nos (Table 3). Compared with whites,Latinos also have twice the percentageof new HIV/AIDS diagnoses amongthose younger than 13 years old, inperinatal transmission, and amongother pediatric cases. They also have ahigher crude incidence rate of tuber-culosis. In terms of Latino subgroups,both Mexican American and PuertoRican children have higher adjustedodds of fair or poor health status.
Asthma, Mental Health Care, andSpecial Health Care Needs
An analysis of national data revealedthat Latinos have a higher asthmaprevalence than do whites, and therehas been a substantial increase inLatino asthma prevalence over time(Table 3). Several studies have docu-mented a particularly high asthmaprevalence among Puerto Ricans.Other asthma disparities includehigher adjusted odds of asthma ED vis-its, hospitalizations, activity limita-tions, and the need for urgent care in
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the previous 12 months, as well as ahigher potential asthma burden (diag-nosed plus possible but undiagnosedasthma). Latinos have lower adjustedodds of use of inhaled steroids and ofdaily anti-inflammatory medications.Disparities among Latino subgroups(compared with white children) in-clude higher adjusted odds of asthmaED visits and hospitalizations amongPuerto Ricans, Dominicans, and “otherLatinos” (except Mexican Americans)and higher adjusted odds of cockroachand dust mite allergen sensitivityamong Mexican Americans.
Eleven studies documented Latino dis-parities in mental health care and be-havioral/developmental issues (Table3). Disparities included significantlyhigher unmet need for mental healthcare, and lower odds of any mentalhealth visit, outpatient visits, antide-pressant prescriptions, and receivingtreatment from a mental health spe-cialist for any condition, behaviorproblems, or depression. Latinos havehigher odds of developmental delaysbut lower odds of being diagnosedwith externalizing behavioral disor-ders. Lower odds were noted for use ofmental health services among chil-dren being investigated for possibleabuse or neglect and among Medicaid-eligible teenagers in substance abusetreatment, although 1 study foundhigher odds of use of state-fundedmental health services in New YorkCity. Latinos have substantially loweradjusted odds of receiving an ADHD di-agnosis or receiving stimulant pre-scriptions during outpatient primarycare visits. Young Latino children havehigher adjusted odds of being read toless than every day, of having fewernumbers of children’s books in thehousehold, and of the family never eat-ing lunch or dinner together.
Many disparities have been docu-mented for Latino children with spe-cial health care needs, including
higher adjusted odds of being unin-sured, having no usual source of care,parental dissatisfaction with care,having unmet medical care needs, nothaving seen the physician in the pastyear, not receiving adequate time andinformation from the health care pro-vider, averaging fewer doctor visitsper year, experiencing difficulties re-ceiving specialty referrals, having fam-ily members reduce or stop employ-ment because of the child’s condition,not receiving family-centered care,and experiencing problems with easeof use of health care services.
Quality
Compared with white children, Latinochildren have higher adjusted odds ofbeing assigned to a health care pro-vider and lower adjusted scores forcomprehensiveness of primary careand primary care provider strength ofaffiliation, interpersonal relationship,and participatory decision-making (Ta-ble 3). Latino children have a shorteraverage well-child visit duration, loweradjusted odds of receiving any coun-seling during well-child visits, andgreater adjusted odds of the parentnot being very likely to recommend thechild’s health care provider, of thehealth care provider never or onlysometimes understanding the child’sspecific needs and how the parent pre-fers to rear the child, and of the pro-vider discussing violence in the com-munity and use of alcohol or drugs inthe household. Similar disparities inthe quality of primary care were notedfor Latino children living in householdsin which English is not the primary lan-guage spoken (in comparison withwhite children).
Among those seen in the ED with acutegastroenteritis, Latino children hadlower adjusted odds than white chil-dren of undergoing 2 or more diagnos-tic tests and of having undergone radi-ography (Table 3). Among children
with supracondylar humerus frac-tures, Latinos were more likely to un-dergo closed reduction with internalfixation.
American Indians and AlaskaNatives
Sixteen articles (15%) addressed dis-parities in AI/AN children, which is thefewest articles for any racial/ethnicgroup (Table 4).
Mortality
AI/AN children have a higher age-specific crude mortality rate com-pared with that of white children, bothin national and urban samples (Table4). A higher adjusted risk of death alsohas been documented for AI/AN chil-dren with ALL.
Use of Health Services
AI/AN children have higher adjustedodds than white children of going 1year or longer since their last physi-cian visit (Table 4).
Prevention and Population Health
Data from the state of Minnesota re-veal a firearm injury rate for AI/AN chil-dren that is more than 7 times higherthan that for their white counterparts(Table 4). Several studies have docu-mented higher adjusted odds of over-weight and obesity among AI/AN chil-dren. Other studies have shown aslower adjusted 1-mile run/walk timeand lower calcium intake among AI/ANboys.
Adolescent Health Issues
Female AI/AN adolescents have higherrisks than their white counterparts ofneeding but not getting medical careand of perpetrating violence (Table 4).Male AI/AN adolescents have a higherrisk than their white counterparts ofskipping breakfast, having poor/fairhealth status, and perpetrating vio-lence. National data from 2 studies re-vealed that the birth rate for AI/AN fe-
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male adolescents is 2 to 3 times higherthan that of white adolescents.
Health Status
AI/AN children have higher adjustedodds than do white children of beingin poor or fair health and the highestprevalence of these suboptimalhealth ratings of any racial/ethnicgroup (Table 4).
Mental Health Care
Within 6 months of a new episode ofdepression, AI/AN children have loweradjusted odds than white children ofany mental health visit or antidepres-sant prescription being filled. AI/ANyouth in treatment for substanceabuse also have a lower adjusted like-lihood of mental health services use.
Quality
Compared with the parents of whitechildren, the parents of AI/AN childrengave lower adjusted scores for their
child’s health care timeliness, healthcare provider communication, andhealth insurance plan service, andlower adjusted ratings for their child’spersonal doctor and health plan (Table4). National data also reveal lower ad-justed odds of being diagnosed withany eye or vision condition.
Multiracial Children
The search terms did not yield any ar-ticles on disparities amongmultiracialchildren.
DISPARITIES AMONGRACIAL/ETHNIC SUBGROUPS
Fifteen studies (14%) included analy-ses of disparities in 1 or more racial/ethnic subgroup (in comparison withwhite children). Five studies of APIs(21% of all studies of APIs) and 10 stud-ies of Latinos (15% of all studies of Lati-nos) examined racial/ethnic subgroupdisparities; none of the analyses for AA
or AI/AN children included subgroupanalyses.
STUDIES EVALUATINGINTERVENTIONS TO REDUCEDISPARITIES
The search terms yielded only 2 stud-ies that evaluated interventions to re-duce racial/ethnic disparities (Table5). A quasi-experimental evaluation ofa school-based Internet and video in-tervention that focused on healthsnacks and gym labs resulted in signif-icant reductions in dietary fat intakeamong all 3 minority groups as well asamong those in the white group, andsignificant increases in physical activ-ity among low-income children in all 3minority groups and white children. Itwas unclear, however, what the con-trol group received, there was nooverall difference between interven-tion and control children in fat-intake reduction, and participants in
TABLE 5 Results of Studies Evaluating Interventions to Reduce Disparities in the Health and Health Care of Minority Children
Disparity Targeted Findings Study Design Sample Size(s) Notes Ref No.
Nutrition and exercise inmiddle-school children
Dietary fat intake significantlyreduced in intervention-group girls for AA, Latino,AI/AN, and white children;significantly increasedphysical activity amongthose with lowest incomeamong AA, Latino, Asian,and white children
Quasi-experimental evaluationof a 4-session Internet andvideo intervention withhealthy snack and gymlabs; intervention occurredin 2 urban, low- to middle-income middle schools(gym lab in 1) in theMidwest
Small sample sizes from only2 schools; unclear whatcontrol group received (ifanything); unclear whenpostinterventionevaluation occurred; nooverall difference betweenintervention and controlchildren in fat intakereduction; both groupsactually decreased theiramount of physical activity
135
Immunization rates among0- to 2-y-olds
No statistically significantdifferences (vs whitechildren) inpostinterventionpopulation immunizationrates for 24-mo-oldsamong AA and Latinochildren; no statisticallysignificant difference (vswhite children) inpostinterventionpopulation immunizationrate for Latino (but not AA)12-mo-olds
Prepopulation/postpopulationstudy in Monroe County,New York, of impact ofcommunity-wide reminder,recall, and outreachsystem for childhoodimmunizationsadministered by layoutreach workers in 8practices (expanded to 10after 4 y). Outcomes weremonitored in a 10%random sample selectedfrom suburban practicesand a 25% random samplefrom urban practices.
Total sample: N�20 132a
9%–74% of cohort(depending on studyregion) did not receiveintervention; immunizationrates unadjusted (notadjusted for any potentialconfounders)
136
a Sample sizes were not disaggregated in article according to race/ethnicity.
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both the intervention and controlgroups decreased their amount ofphysical activity.
A preintervention and postinterventionstudy in an upstate New York county ofthe effects of a community-wide re-minder, recall, and outreach systemfor childhood immunizations resultedin no statistically significant differ-ences from 24-month-old white chil-dren in postintervention immunizationrates for 24-month-old AA and Latinochildren, and no statistically signifi-cant difference between only Latinoand white 12-month-old children inpostintervention immunization rates.Up to 74% of the cohort, however, didnot receive the intervention in somecounty regions, and the immunizationrates were not adjusted for confound-ers.
METHODOLOGIC ISSUES
Failure to evaluate children separatelyfrom adults was the most commonreason for exclusion of studies fromthe final database, accounting for 27(22%) of the excluded studies. Anothercommonly encountered methodologicissue was the combination of all non-white children into 1 group, which oc-curred in 11 (9%) of the excluded stud-ies. An additional 10 studies (8%) failedto provide a white comparison group.Among the 109 studies in the final da-tabase, 27 (22%) did not perform mul-tivariable or stratified analyses to en-sure that racial/ethnic disparitiespersisted after adjustment for socio-economic status (SES) and other po-tential confounders.
IMPLICATIONS
Extensiveness and Pervasivenessof Disparities
A comprehensive review of the litera-ture revealed that racial/ethnic dis-parities in children’s health and healthcare are quite extensive, pervasive,and persistent. Disparities were noted
across the spectrum of health andhealth care, including in mortality rates,access to care and use of services, pre-vention and population health, healthstatus, adolescent health, chronic dis-eases, special health care needs, qual-ity of care, and organ transplantation.In addition, the data indicate that ra-cial/ethnic disparities are persistingor worsening over time, at least in thefew areas for which data from secular-trend studies are available, such asoverall mortality rates, elevated bloodlead concentrations, and asthma prev-alence, mortality, and hospitalizations.
Mortality and Chronic Disease
Although racial/ethnic disparities inadult mortality21 and chronic disease22
rates have receivedmuch attention, lit-tle attention has been paid to these is-sues in children (other than for infantmortality). Nevertheless, review of theliterature identified disparities in mor-tality rates for all 4 major racial/ethnicgroups of US children. The extent anddiversity of these mortality-rate dis-parities are concerning: these dispar-ities include substantially greaterrisks than for white children of all-cause mortality; death from drowning,from ALL, from congenital heart de-fects, and after congenital heart defectsurgery; and an earlier median age atdeath for those with Down syndromeand congenital heart defects. Addi-tional research is needed to determinewhether other racial/ethnic dispari-ties exist in childhood mortality rates,the causes of these disparities, andinterventions that are effective in re-ducing or eliminating mortality-ratedisparities.
Extensive childhood disparities werefound for chronic diseases, includingasthma, cancer, eye disorders, HIV/AIDS, kidney disease, mental health,special health care needs, and stroke.In particular, multiple studies havebeen conducted on disparities in
asthma, mental health, and specialhealth care needs. Nevertheless, manygaps exist in the literature, and fur-ther study is needed to determinethe etiology of and effective interven-tions for disparities in childhoodchronic diseases.
Disparities as a Quality Issue
It has been suggested that a useful ap-proach to addressing racial/ethnicdisparities in children’s health care isto frame disparities as a quality-of-care issue.23 This review of the litera-ture identified multiple racial/ethnicdisparities in the quality of children’shealth care, including inequalities inthe quality of primary care, asthmacare, cardiovascular surgery, mentalhealth care, pneumonia hospitaliza-tions, ophthalmologic care, orthopedicconditions, and care of children withend-stage renal disease. Additionalstudy is warranted, not only of the eti-ology and pervasiveness of disparitiesin the quality of pediatric care, but alsoof interventions that would be effectivein achieving quality improvementamong racial/ethnicminority children.
Research Implications
In the course of reviewing the dispari-ties literature, certain key method-ologic and research issues were iden-tified. Attention to these issues has thepotential to advance the field and en-hance the rigor of studies. A total of 48studies were excluded from the data-base because they combined all minor-ity children into a nebulous “nonwhite”category, failed to include a compari-son group consisting of white children,or did not perform separate analyseswith children disaggregated fromadults.
Occasionally, theremay be statisticallylegitimate reasons to not comparestudy findings for specific minority ra-cial/ethnic groups with those of whitechildren (such as when there truly are
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small sample sizes for specific minor-ity groups in the study population). Therecurrent findings in the literature,however, of combining minority chil-dren into a “nonwhite group” and fail-ure to collect data for specific, popu-lous minority groups of children raiseseveral key issues. It is critical thatcurrent and future pediatric researchbe relevant, meaningful, and generaliz-able for all children. The explosivegrowth in racial/ethnic diversity of USchildrenmakes it imperative that pedi-atric research funding not ignore spe-cific questions or populations. In addi-tion, as new interventions, practices,and technologies are evaluated, it isimportant to consider translational re-search on the application of these in-novations to diverse populations andsettings.
Almost one-quarter of the excludedstudies did not use multivariable orstratified analyses to adjust for covari-ates that might confound disparitiesfindings. For several domains, such asmental health, asthma, and vision dis-orders, there is an unresolved issuethat warrants further investigation; itis unclear whether (1) a general qual-ity issue exists for minority children ofunderdiagnosis and undertreatmentof certain conditions, (2) there is alower prevalence of these conditionsin certain groups, (3) racial/ethnic dif-ferences occur in access or treatmentpreferences, or (4) some combinationof these phenomena apply.
More disparities research is neededon API and AI/AN children, because apaucity of studies on these groups wasidentified. The few studies that exam-ined relevant subgroups of racial/eth-nic minority children identified note-worthy racial/ethnic disparities. Moreresearch is needed on childhood dis-parities among black subgroups (suchas AAs versus Caribbean blacks versusrecent African immigrants), Latinos
(such as Mexican Americans, PuertoRicans, and Cuban Americans), AIs/ANs (such as major tribal groups), andAPIs (such as Chinese Americans ver-sus Vietnamese versus Hmong). Ourcall for more studies on racial/ethnicsubgroup disparities echoes a recom-mendation published 15 years ago bythe AAP Task Force on Minority Chil-dren’s Access to Pediatric Care thatmore attention be paid to the hetero-geneity of API populations.24
Limitations
Certain limitations of this literature re-view should be noted. The literaturesearch consisted of studies from 1950through March 2007, so studies afterMarch could not be included. Becausethe search strategies only identifiedpublished citations with “disparities”as a key word, studies that reporteddisparities or disparities interventionsbut did not use this key word wouldhave been missed; in particular, re-search from earlier years before the“disparities” term enjoyed wider us-age would have been overlooked. Thefocus was on racial/ethnic disparities,so studies that documented a lack ofdisparities were not reviewed. Only21 studies, however, were excludedthat found no significant differencesaccording to race/ethnicity, equiva-lent to 9% of the database of full-print studies examined, and 17% ofall exclusions.
Interventions to ReduceDisparities
This literature review identified only 2studies that evaluated interventions toreduce racial/ethnic disparities inchildren’s health and health care andthat also compared theminority groupto a white group, and none was a ran-domized, controlled trial. These find-ings suggest that there is a need forrigorous evaluations of interventionsaimed at reducing childhood dispari-ties, especially in light of the substan-
tial number of studies identified thatdocumented a wide variety of racial/ethnic disparities in children’s healthand health care.
Only articles that examined racial/ethnic disparities in the context ofcomparisons to white children wereincluded in the literature review. Forcertain health outcomes for whichracial/ethnic disparities are welldocumented, published studies mayonly have focused on disparities in-terventions limited to a single minor-ity group. Because the literature-search inclusion criteria requiredcomparison between a minoritygroup and a white group, successfuldisparities-intervention studies lim-ited to a single minority group wereexcluded, by necessity, from thistechnical report, such as recent ran-domized trials of interventions to in-sure uninsured Latino children andprevent HIV in AA girls.25,26
CONCLUSIONS
This technical report documents thatracial/ethnic disparities in chil-dren’s health and health care are ex-tensive, pervasive, and persistent.Disparities were noted across thespectrum of health and health care,including in mortality rates, accessto care and use of services, preven-tion and population health, healthstatus, adolescent health, chronicdiseases, special health care needs,quality of care, and organ transplan-tation. Methodologic flaws wereidentified in how such disparities aredocumented and analyzed. Withoutrecognition of child health dispari-ties as pervasive problems, soundmethodologies to assess the magni-tude of disparities, and rigorousevaluation of disparities interven-tions, the pediatric community willnot be able to realize the vision of theAAP to attain optimal physical, men-
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tal, and social health and well-beingof all infants, children, adolescents,and young adults.
COMMITTEE ON PEDIATRIC RESEARCH,2008–2009Scott C. Denne, MD, ChairpersonAndrew J. Bauer, MD*Michael D. Cabana, MD, MPHTina L. Cheng, MD†Glenn Flores, MDDaniel A. Notterman, MD
LIAISONSDuane F. Alexander, MD – Eunice KennedyShriver National Institute of Child Healthand Human DevelopmentClifford W. Bogue, MD – Society for PediatricResearchLaurence A. Boxer, MD – American PediatricSocietyChristopher A. DeGraw, MD, MPH – Maternaland Child Health BureauDenise Dougherty, PhD – Agency forHealthcare Research and QualityBenard P. Dreyer, MD – Academic PediatricAssociation
Elizabeth Goodman, MD – Society forAdolescent MedicineA. Craig Hillemeier, MD – Association ofMedical School Pediatric Department ChairsLewis H. Margolis, MD, MPH – American PublicHealth AssociationJessica Shand, MD – AAP Section on ResidentsPaul P. Wang, MD – Society for Developmentaland Behavioral Pediatrics
STAFFWilliam L. Cull, PhD
*Contributing author†Lead author
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DOI: 10.1542/peds.2010-0188 originally published online March 29, 2010; 2010;125;e979Pediatrics
Glenn Flores and THE COMMITTEE ON PEDIATRIC RESEARCHRacial and Ethnic Disparities in the Health and Health Care of Children
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