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Child Health Disparities
Health and illness are not distributed equally among all members in most societies. Differences exist in risk factors, prevalence and incidence, manifestations, severity, and outcome of health conditions, as well as in the availability and quality of healthcare. When these differences are modifiable and avoidable, they are referred to as disparities or inequities . The U.S. Department of Health and Human Services (DHHS) Healthy People 2020 report defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” The U.S. Centers for Disease Control and Prevention (CDC) define health disparities as “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” Health and healthcare disparities occur by nature of unequal distribution of resources that are inherent in societies that exhibit social stratification , which occurs in social systems that rank and categorize people into a hierarchy of unequal status and power. There exists a hierarchy of “haves and have nots” based on group classifications.
Although there are many differences regarding health status, not all these differences are considered disparities. The increased prevalence of sickle cell disease in people of African descent, or the increased prevalence of cystic fibrosis in white individuals of Northern European descent, would not be considered a disparity because—at least at present—the genetic risk is not easily modifiable. However, in 2003, funding was 8-fold greater per patient for cystic fibrosis than for sickle cell disease, which could be considered a disparity because it is modifiable.
Health and healthcare disparities have existed for centuries. A critical mass of research building in the mid-2000s corresponded to the U.S. Institute of Medicine's 2003 book, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare . It reviewed the literature on racial and ethnic disparities in health and healthcare and found 600 citations.
Determinants of Health and Health Disparities
Fig. 2.1 displays a categorization of the multiple determinants of health and well-being. Applying this categorization to health disparities, conceptualizations of the root causes of health disparities emphasize the most modifiable determinants of health: the physical and social environment, psychology and health behaviors, socioeconomic position and status, and access to and quality of healthcare. Differential access to these resources result in differences in material resources (e.g., money, education, healthcare) or psychosocial factors (e.g., locus of control, adaptive or risky behaviors, stress, social connectedness) that may contribute to differences in health status.
Fig. 2.2 illustrates the complex relationships among multileveled factors and health outcomes. Social stratification factors such as socioeconomic status (SES), race, and gender have profound influences on environmental resources available to individuals and groups, including neighborhood factors (e.g., safety, healthy spaces), social connectedness and support, work opportunities, and family environment. Much of the differential access to these resources results from discrimination, on a systematic or interpersonal level. Discrimination is defined as negative beliefs, attitudes, or behaviors resulting from categorizing individuals based on perceived group affiliation, such as gender (sexism) or race/ethnicity (racism).
SES, race/ethnicity, gender, and other social stratification factors also have effects on psychological functioning, including sense of control over one's life, expectations, resiliency, negative affect, and perceptions of and response to discrimination. Environmental and psychological context then have influence over more proximal determinants of health, including health-promoting or risk-promoting behaviors; access to and quality of healthcare and health education; exposure to pathogens, toxins, and carcinogens; pathophysiologic (biologic) and epigenetic response to stress; and the resources available to support optimal child development. Variability in these factors in turn results in differential health outcomes.
Psychosocial Stress and Allostatic Load
An understanding has emerged that helps explain how psychosocial stress influences disease and health outcomes ( Fig. 2.3 ). This theory, allostatic load , provides insight into the processes and mechanisms that may contribute to health disparities. Allostasis refers to the normal physiologic changes that occur when individuals experience a stressful event. These internal reactions to an external stressor includes activation of the stress-response systems, such as increases in cortisol and epinephrine, changes in levels of inflammatory and immune mediators, cardiovascular reactivity, and metabolic and hormone activation. These are normal and adaptive responses to stress and result in physiologic stability in the face of an external challenge. After an acute external stress or challenge, these systems revert to normal baseline states. However, when the stressor becomes chronic and unbuffered by social supports, dysregulation of these systems may occur, resulting in pathophysiologic alterations to these responses, such as hyperactivation of the allostatic systems, or burnout. Over time this dysregulation contributes to increased risk of disease and dysfunction. This pathophysiologic response is called allostatic load .
Given the systems affected (e.g., metabolic, immune, inflammatory, cardiovascular), allostatic load may contribute to increase incidence of chronic diseases such as cardiovascular disease, stroke, diabetes, asthma, and depression. It is notable that these specific chronic diseases have increased prevalence in racial and ethnic minority groups. Racial and ethnic minorities experience significantly higher degrees of chronic psychosocial stress (see Fig. 2.2 ), which over time contributes to allostatic load and the resultant disparities in these chronic diseases. Many of these conditions are noted to occur in adulthood, demonstrating the life course consequences of chronic psychosocial stress and adversity that begins in childhood.
The allostatic load model provides a pathophysiologic mechanism through which social determinants of health contribute to health disparities. It complements other mechanisms noted in Fig. 2.2 , such as differential access to healthcare, increase in health risk behaviors, and increased exposure to pathogens, toxins, and other unhealthy agents.
The Hispanic Paradox
Whereas data suggest that minority racial and ethnic groups typically have worse health outcomes than the majority white group, this is not always the case. This finding demonstrates the complex interrelationship among race/ethnicity, minority status, and other factors that contribute to disparities, such as social class and SES.
Studies suggest that for many health outcomes, Hispanic/Latino populations do significantly better than other minority racial/ethnic groups and sometimes as well as the majority non-Hispanic white population. This finding has been called the Hispanic Paradox (also known as the Latino Paradox, Epidemiologic Paradox, Immigrant Paradox, and Health Immigrant Effect). Hispanic life expectancy is about 2 yr higher than for non-Hispanic whites, and mortality rates are lower for 7 of the 10 leading causes of death. Among child health issues, Hispanics in general have lower rates of prematurity and low birthweight than African Americans, and Mexican Americans have lower rates of asthma than African Americans and non-Hispanic whites.
Several hypotheses may explain these epidemiological findings. First, the relative advantages seen in Hispanic health are greatest for non–U.S.-born Hispanics , and many of the health advantages become nonsignificant in second- or third-generation U.S. Hispanics (as individuals spend more time in the United States). Thus, indigenous cultural beliefs and lifestyles brought over by Hispanic immigrants may provide a selective health advantage, including low rates of tobacco and illicit drug use, strong family support and community ties, and healthy eating habits. Health advantages disappear as immigrants become more acculturated to U.S. standards—poorer nutritional habits and tobacco, alcohol, and illicit drug use—supporting this theory. It is also hypothesized that those who immigrate to the United States are younger and healthier than those Hispanics who do not immigrate and stay in their country of origin, so there may be a selection bias; Hispanic immigrants may start out healthier on arrival. Recent immigrants also tend to reside in ethnic enclaves, and socially supportive residential environments are associated with better health outcomes. When immigrants acculturate to U.S. lifestyles, not only do they acquire unhealthy behaviors, but they also tend to lose the protective aspects of their original culture and lifestyle.
There are also differences in outcomes among different Hispanic/Latino subgroups. Selective advantages in Hispanics are usually found among Hispanics from Mexico or South/Central America. Puerto Rican Hispanics typically have worse outcomes, compared to other Hispanic groups and non-Hispanic whites. Puerto Rico is a U.S. territory (Puerto Ricans are not immigrants) and has many of the negative health profiles seen in the mainland (e.g., high rates of tobacco rates and other health risk behaviors), which further supports the importance of indigenous, healthy, cultural behaviors and lifestyle as an explanation for the healthy immigrant profile seen in Central and South American Hispanics.
Disparities in Child Health and Healthcare:
Tables 2.1 and 2.2 display some of the known disparities in child health and healthcare. As previously noted, health disparities may occur as a result of race/ethnicity,socioeconomic status (often operationalized through family income, sometimes using insurance status as a proxy), and residency patterns, such as urban and rural locale.
Table 2.1
Child Health Disparities
| HEALTH INDICATOR | RACE/ETHNICITY | FAMILY INCOME | RESIDENCE |
|---|---|---|---|
| Child health status fair or poor | Black & Hispanic > White & Asian | Poor > Not Poor | |
| Children with special health care needs (CSHCN) | Black > White > Hispanic | Poor > Not Poor | |
| One or more chronic health conditions | Black > White > Hispanic > Asian | Poor > Not Poor | |
| Asthma | Mainland Puerto Rican > Black > White & Mexican American | Poor > Not Poor | Urban > Rural |
| Obesity | Hispanic & Black > White and Asian | Poor > Not Poor | Rural > Urban |
| Infant mortality | Black > Hispanic > White | Poor > Not Poor | |
| Low birthweight (<2,500 g.) | Black > White, Hispanic, American Indian/Native Alaskan, Asian/Pacific Islander Mainland Puerto Rican > Mexican American |
Poor > Not Poor | |
| Preterm birth (<37 wk) | Black > American Indian/Native Alaskan, Hispanic, White, Asian/Pacific Islander Mainland Puerto Rican > Mexican American |
Poor > Not Poor | |
| Seizure disorder, epilepsy | Black > White, Hispanic | Poor > Not Poor | |
| Bone, joint, or muscle problem | White > Black, Hispanic | Poor > Not Poor | |
| Ever breastfed | White, Hispanic, Asian > Black | Not Poor > Poor | Urban > Rural |
| No physical activity in the past week | Hispanic > Black, Asian > White Poor > Not Poor |
Poor > Not Poor | |
| Hearing problem | Poor > Not Poor | ||
| Vision problem | Poor > Not Poor | ||
| Oral health problems (including caries and untreated caries) | Hispanic > Black > White, Asian | Poor > Not Poor | Rural > Urban |
| Attention-deficit/hyperactivity disorder (ADHD) | White, Black > Hispanic | Poor > Not Poor | Rural > Urban |
| Have ADHD but not taking medication | Hispanic, Black > White | ||
| Anxiety problems | White > Black, Hispanic | Poor > Not Poor | |
| Depression | Poor > Not Poor | Rural > Urban | |
| Behavior or conduct problem (ODD, conduct disorder) | Black > White, Hispanic | Poor > Not Poor | |
| Autism Spectrum Disorder | White > Black > Hispanic | Poor > Not Poor | |
| Learning disability | Black > White, Hispanic | Poor > Not Poor | Rural > Urban |
| Developmental delay | Black > White > Hispanic, Asian | Poor > Not Poor | |
| Risk of developmental delay, by parental concern | Hispanic > Black & White | Poor > Not Poor | |
| Speech or language problems | Poor > Not Poor | ||
| Adolescent suicide attempts (consider, attempt, needed medical attention for an attempt) | Girls: Hispanic > Black & White Boys:Hispanic & Black > White |
||
| Adolescent suicide rate | Girls: American Indian > White, Asian/Pacific Islander, Hispanic, Black Boys: American Indian & White > Hispanic, Black, Asian/Pacific Islander |
||
| Child maltreatment (reported) | Black, American Indian/Alaskan Native, Multiracial > White, Hispanic, Asian, Pacific islander | Poor > Not Poor | |
| AIDS (adolescents) | Black > Hispanic > White |
AIDS, Acquired immunodeficiency syndrome; ODD, oppositional defiant disorder.
Table 2.2
Child Healthcare Disparities
| HEALTHCARE INDICATOR | RACE/ETHNICITY | FAMILY INCOME | RESIDENCE |
|---|---|---|---|
| Did not receive any type of medical care in past 12 mo | Hispanic, Black, Asian > White | Poor > Not Poor | Rural > Urban |
| No well-child checkup or preventive visit in past 12 mo | Hispanic > White & Black | Poor > Not Poor | Rural > Urban |
| Delay in medical care | Hispanic > Black > White | Poor > Not Poor | |
| Unmet need in healthcare due to cost | Black > Hispanic > White > Asian | Poor > Not Poor | |
| No coordinated, comprehensive, or ongoing care in a medical home | Hispanic > Black & Asian > White | Poor > Not Poor | Rural > Urban |
| Problem accessing specialist care when needed | Hispanic & Black > White | Poor > Not Poor | |
| No preventative dental care visit in past 12 mo | Hispanic & Asian > Black > White | Poor > Not Poor | Rural > Urban |
| No vision screening in past 2 yr | Hispanic & Asian > Black & White | Poor > Not Poor | |
| Did not receive needed mental health treatment or counseling in past 12 mo | Black & Hispanic > White | Poor > Not Poor | |
| Not receiving a physician recommendation for HPV vaccination among 13-17-yr- old girls | Black & Hispanic > White | ||
| Immunization rates: adolescent HPV vaccine | Girls: White > Black & Hispanic Boys: Black & Hispanic > White |
HPV, Human papillomavirus.
Child Health Disparities
Asthma
Disparities in asthma prevalence are seen by racial/ethnic group and SES. According to the 2015 U.S. National Health Interview Survey (NHIS), American Indian/Alaskan Native, Mainland Puerto Rican, and African American children have the highest prevalence of childhood asthma (14.4%, 13.9%, and 13.4%, respectively), followed non-Hispanic white (7.4%) and Asian (5.4%). The prevalence of childhood asthma in Hispanics is 8%, but when the Hispanic category is disaggregated, Mexican Americans have a prevalence of 7.3%, which is lower than that for non-Hispanic whites; Puerto Rican children have among the highest rates of asthma. The cause of this difference among Hispanic/Latino subgroups is debatable, but some data suggest that bronchodilator response may be different in the 2 groups, possibly based on genetic variants. Data also suggest that within the Mexican American population, differences in prevalence exist based on birthplace or generation (see earlier, The Hispanic Paradox ): immigrant and first-generation Mexican American children have lower prevalence of asthma than Mexican American children who have lived in the United States longer. This may reflect the changes that occur as Latinos become more acculturated to U.S. behavioral norms the longer they reside in the United States (e.g., tobacco use, dietary patterns, environmental exposures).
Regarding SES, children living at <100% the federal poverty level have a childhood asthma prevalence of 10.7%, whereas those living at ≥200% the poverty level have a prevalence of 7.2%.
Obesity
In 2014 the percentage of Hispanic/Latino children in the National Health and Nutrition Examination Survey (NHANES) age 6-17 yr who were obese was 24.3%. The percentage of African American children who were obese was 22.5%. This compares to non-Hispanic whites (17.1%) and Asian (9.8%) (see Fig. 2.3 ). Dietary patterns, access to nutritious foods, and differing cultural norms regarding body habitus may account for some of these differences. The relationship between SES and childhood obesity is less clear. Some studies suggest that the racial and ethnic differences in childhood obesity become nonsignificant when factoring in family income, whereas other national survey studies suggest a relationship between family income and obesity rates in non-Hispanic whites but not among black or Mexican American children.
Infant Mortality
Highest rates of infant mortality are seen in non-Hispanic black infants. According to data from the 2007–2008 National Center for Health Statistics (NCHS)–linked Live Birth–Infant Death Cohort Files, the odds ratio for non-Hispanic black infant mortality is 2.32, compared to non-Hispanic white rates, and remains significant after controlling for maternal age, education, marital status, parity, plurality, nativity, tobacco use, hypertension, and diabetes. Compared with non-Hispanic whites, higher infant mortality is also seen in Hispanic black and Hispanic white infants as well.
In 2012 the infant mortality rate for black, non-Hispanic (11.2/1,000 live births) and American Indian/Alaskan Native (8.4/1,000) infants was higher than for white, non-Hispanic (5.0/1,000), Hispanic (5.1/1,000), and Asian/Pacific Islander (4.1/1,000) ( Fig. 2.4 ). There was variation in the U.S. Hispanic population: the Puerto Rican infant mortality rate was 6.9/1,000, compared to 5.0/1,000 for Mexican Americans and 4.1/1,000 for Central and South American origin.
Prematurity and Low Birthweight
There are significant black-white differences in preterm birth and low birthweight (LBW) ( Fig. 2.5 ). According to the 2014 NCHS National Vital Statistics System, LBW births (<2500 g) were significantly higher among black non-Hispanic women (13.2%) than white non-Hispanic (7.0%), American Indian/Alaskan Native (7.6%), Asian/Pacific Islander (8.1%), or Hispanic (7.1%) women. Among Hispanics, Puerto Rican women had higher rates of LBW births than Mexican Americans (9.5% vs 6.6%).
Regarding preterm births (<37 wk), the black non-Hispanic rate was 13.2%, compared to 8.9% for white non-Hispanics, 8.5% for Asian/Pacific Islanders, 10.2% for American Indian/Alaskan Native, and 9% for Hispanics. Within the Hispanic group, the Puerto Rican preterm rate was higher than for Mexican Americans (11% vs 8.8%).
There are many hypotheses for the increased rates of preterm birth and LBW in black births. Risk factors such as inadequate prenatal care, genitourinary tract infections, increased exposure to environmental toxins, and increased tobacco use may account for some of the disparity, but not all, and neither do SES differences, since high-SES black women still have higher rates of premature and LBW births.
Increased stress has been presented as a potential mechanism. Studies have shown that minority women who experience perceptions of racism and discrimination have higher odds of delivering a preterm or LBW child than do minority women who have not perceived experiences with discrimination. Residential segregation is also a potential source of differences in preterm and LBW outcomes. Living in hypersegregated neighborhoods can decrease access to prenatal care, increased exposure to environmental pollutants, and increase psychosocial stress, all of which may contribute to increased risk.
Increased age at delivery in African American women does not lessen the risk of preterm or LBW delivery (as it does in white mothers). This has led to the theory that cumulative stress in black women, related to chronic exposure to factors such as socioeconomic deprivation and racial discrimination, leads to declining health at an earlier age compared with white women, and thus increases the risk for poor pregnancy outcomes. Called the weathering hypothesis , this has been proposed as an explanation for racial variations in pregnancy outcomes.
Oral Health
Significant differences exist in oral health status as well as preventive oral healthcare according to race/ethnicity, SES, and residency locale. Data from the 1994–2004 NHANES show that compared to non-Hispanic white children, black and Mexican American children had higher rates of caries and untreated caries and lower rates of receiving dental sealants. Children living at or below the federal poverty level also had higher rates of caries and untreated caries and lower rates of dental sealant applications, compared with nonpoor children.
Preventive oral healthcare may improve rates of caries and treat caries before further impairment ensues. Data from the 2004 Medical Expenditure Panel Survey revealed that only 34.1% of black and 32.9% of Hispanic children had a yearly visit to a dentist, compared to 52.5% of white children. Likewise, only 33.9% of low-income children had dentist visits, compared to 46.5% of middle-income children and 61.8% of high-income children.
According to the 2011/12 National Survey of Children's Health (NSCH) , parents reported fair to poor teeth condition at a higher rate in Asian non-Hispanic children (8.5%), black non-Hispanic children (7.6%), and Hispanic children (15.2%), compared to white children (4.2%). Hispanic and black non-Hispanic children had higher rates of oral health problems than white non-Hispanic and Asian non-Hispanic children as well.
Hearing Care
No data suggest that the prevalence of hearing loss (either congenital or acquired) is different among racial/ethnic or SES categories, but follow-up care after diagnosis of a hearing problem has been shown to be worse in certain groups. Higher “lost to follow-up” rates have been noted in children living in rural areas as well as with publically insured and nonwhite children. Much of this disparity is reduced when families have access to specialists.
Vision Problems
The parent-reported 2011/12 NSCH found no differences in the prevalence of correctable vision problem among white non-Hispanic, black non-Hispanic, Hispanic, and “other” racial/ethnic groups, or with regard to SES or urban/rural residence.
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