1
Unequal Treatment for Young Children?
Racial and Ethnic Disparities in
Early Childhood Health and Healthcare
Glenn Flores, MD,1 Sandy Tomany, MS1
and Lynn Olson, PhD2
1Department
of Pediatrics,
Medical College of Wisconsin and Children’s Hospital of Wisconsin;
2Department of Practice & Research, American Academy of Pediatrics
Funding: Robert Wood Johnson Foundation, AHRQ, Gerber Foundation
2
Background


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US experiencing demographic surge in minority
children, particularly among youngest age groups
By 2030
 There will be more minority children
than non-Hispanic white children 0-18 years old
 Among 0-5 year olds, minorities will outnumber
non-Hispanic whites by 1.1 million
As number and proportion of minority children grow,
racial/ethnic disparities will take on even greater
importance for pediatric providers
3
Background



Recent reports by IOM and AHRQ called attention to
tendency for US minorities to receive lower quality
healthcare than whites, even after adjustment
for access-related factors
Although multiple studies document racial/ethnic
disparities in adults, few studies have examined
such disparities in children
 For example, only 5 of 103 studies in IOM’s extensive
literature review specifically addressed
disparities in children
In particular, little known about whether younger children
experience racial/ethnic disparities in healthcare
4
Study Aim

To examine racial/ethnic disparities in
early childhood health and healthcare
using nationally representative sample
Methods: Data Source- National Survey
of Early Childhood Health (NSECH)
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
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Telephone survey in 2000 of national random sample
of households with children 4-35 months old
Oversampled households with black
and Hispanic children
Parent or guardian most responsible
for child’s healthcare interviewed
2,068 interviews completed
Interview completion rate = 79%
Estimates based on sampling weights generalize to
entire US population of children 4-35 months of age
5
6
Methods: Study Variables



Variables examined included
 Selected sociodemographics
 Healthcare provider characteristics
 Use of health services
 Parental satisfaction with care
 Topics discussed with parents by providers
Children’s race/ethnicity defined as white, black, or
Hispanic by parental report ( “black” and
“Hispanic” = NSECH terms)
Because of insufficient sample sizes, subjects from
other racial/ethnic groups excluded
7
Methods: Statistical Analysis

Multivariable analyses performed to examine
racial/ethnic differences after adjustment for
 Insurance coverage
 Survey language chosen by parent
(English vs. Spanish)
 Health status
 Poverty
 Child’s age
 Parental educational attainment
Characteristics: 4-35 Month-Old
US Children in 2000 (NSECH)
8
White
Black
Hispanic
Characteristic
(N = 718)
(N = 477)
(N = 817)
Mean age (mo)
19.5
19.5
18.7
0.22
Male sex (%)
53
48
51
0.34
Mother not high school grad (%)
11
26
49
<.001
Mother married (%)
81
32
58
<.001
Mother not employed (%)
45
39
53
<.001
Family income at/below poverty level
(%)
13
49
48
<.001
Uninsured (%)
Private insurance (%)
Public insurance (%)
9
72
19
18
32
50
31
29
40
<.001
Child’s health excellent/very good (%)
90
79
72
<.001
P
9
Characteristics: Well Child Care Providers
for 4-35 Month-Old US Children
White
Black
Hispanic
(N = 718)
(N = 477)
(N = 817)
P
Usual medical care in private practice
80%
68%
58%
<.001
No specific well child care provider
52%
61%
63%
<.001
Well child provider assigned to child
7%
14%
19%
.01
Urban provider practice location
50%
66%
76%
<.001
Well child care provider male
63%
51%
56%
.03
Characteristic
10
Parental Satisfaction and Interactions with Well
Child Care Providers: 4-35 Month-Old US Children
White
Black
Hispanic
(N = 718)
(N = 477)
(N = 817)
P
Never/only sometimes took time to
understand child’s specific needs
10%
15%
30%
<.001
Never/only sometimes respects
parent as expert on child
14%
22%
25%
<.001
Never/only sometimes understands
parents’ childrearing preferences
35%
45%
46%
<.001
Never/only sometimes asks
how parent is feeling as parent
55%
53%
61%
<.001
Did not spend enough time with child
during last check-up (parent report)
11%
10%
17%
.02
Parent very likely
to recommend provider
84%
77%
60%
<.001
Provider Characteristic
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Topics Discussed with Parent by Well Child
Care Providers: 4-35 Month-Old US Children
White
Black
Hispanic
(N = 718)
(N = 477)
(N = 817)
P
Violence in community
6%
14%
20%
<.001
Smoking in household
72%
86%
85%
<.001
Alcohol or drug use in household
35%
58%
65%
<.001
Trouble paying for child’s needs
10%
18%
14%
.001
Spouse/partner supports parenting style
34%
46%
46%
<.001
Told parent developmental assessment
done
47%
34%
43%
.001
Immunizations
97%
96%
94%
.16
Food/feeding issues
83%
83%
85%
.78
Car seats
69%
77%
77%
.001
Importance of reading to child
59%
69%
64%
.006
Topic
Use of Selected Health Services:
4-35 Month-Old US Children
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White
Black
Hispanic
(N = 718)
(N = 477)
(N = 817)
Made age-appropriate # of well-child
care visits (by AAP guidelines)
68%
70%
66%
.55
Mean number of phone calls to
doctor’s office in past year
4.2
3.1
2.0
<.001
1 or more ED visits in past year
32%
47%
41%
<.001
1 or more hospital stays in past year
9%
17%
12%
.005
Provider referred child
to specialist
22%
17%
11%
<.001
Measure
P
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Multivariate Analyses: Racial/Ethnic
Disparities for 4-35 Month-Old US Children
Odds Ratio (95% CI)*
Measure
Black
Hispanic
Uninsured
1.7 (1.02, 2.9)
2.3 (1.4, 3.8)
Child’s health not excellent or very good
2.1 (1.3, 3.3)
1.3 (0.8, 2.1)
Parent not very likely to recommend provider
1.2 (0.7, 2.2)
1.9 (1.1, 3.3)
Provider never/sometimes understands child’s needs
1.4 (0.9, 2.3)
2.2 (1.4, 3.6)
Provider never/sometimes understands
parents’ childrearing preferences
1.5 (1.1, 2.2)
1.5 (1.1, 2.2)
Mean # of calls to doctor’s office in past year
-1.1 (-1.8,-0.3) -1.0 (-1.8,-0.2)
One or more ED visits in past year
1.5 (1.1, 2.2)
1.4 (0.96, 2.0)
Child not referred to specialist by provider
1.8 (1.1, 2.9)
1.7 (1.1, 2.8)
*Reference group: white children
14
Multivariate Analyses: Racial/Ethnic
Disparities for 4-35 Month-Old US Children
Odds Ratio (95% CI)*
Topic Discussed with Parent by Provider
Black
Hispanic
Violence in community
2.2 (1.1, 4.4)
2.3 (1.2, 4.4)
Smoking in household
1.9 (1.2, 2.8)
1.5 (0.9, 2.3)
Use of alcohol or drugs in household
2.0 (1.4, 2.8)
1.6 (1.1, 2.3)
Trouble paying for child’s needs
1.7 (1.03, 2.8)
1.3 (0.8, 2.1)
Spouse/partner supports parenting efforts
1.6 (1.2, 2.3)
1.4 (1.0, 2.1)
Childcare arrangements
2.0 (1.4, 2.8)
1.3 (0.9, 1.9)
Importance of reading to child
1.6 (1.1, 2.3)
1.2 (0.8, 1.7)
*Reference group: white children
15
Multivariate Analyses: Parent Survey Language
Disparities for 4-35 Month-Old US Children
Measure
Odds Ratio (95% CI)
Parent Survey in Spanish*
Uninsured
Child’s health not excellent or very good
Usual place for medical care not private/group practice
Provider never/sometimes understands child’s needs
Provider discussed violence in community
Provider discussed use of alcohol or drugs in household
Parent told developmental assessment done by provider
Mean # of calls to doctor’s office in past year
Child not referred to specialist by provider
*Reference group: parent completed survey in English
1.9 (1.2, 2.9)
2.8 (1.7, 4.6)
2.5 (1.6, 3.9)
1.9 (1.2, 3.2)
2.3 (1.4, 3.7)
2.8 (1.8, 4.4)
2.2 (1.4, 3.4)
-2.0 (-2.8, -1.2)
2.7 (1.4, 5.2)
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Conclusions
Young minority children in US and those with
Spanish-speaking parents experience
multiple disparities in
 Insurance coverage
 Health status
 Parental satisfaction with well-child care providers
 Provider understanding of child’s needs
and parents’ childrearing preferences
 Provider discussion of violence and
alcohol/illicit drug use
 Parents’ calls to doctors’ offices
 Specialty referrals
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Implications

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Greater insight needed about why
such racial/ethnic disparities exist
Study findings suggest priority areas
for monitoring, quality assurance, and
provider and system performance evaluation
in health plans and systems providing healthcare
to diverse pediatric populations
Targeted educational interventions,
such as cultural competency training,
might help ensure equal treatment
for all young children in pediatric visits