Glenn Flores

Racial and Ethnic Disparities in Medical and Dental Health, Access to Care, and Use of Services in US Children

BACKGROUND. Not enough is known about the national prevalence of racial/ethnic disparities in childrens medical and dental care. OBJECTIVE. The purpose of this work was to examine racial/ethnic disparities in medical and oral health, access to care, and use of services in a national sample. METHODS. The National Survey of Childrens Health was a telephone survey in 2003–2004 of a national random sample of parents and guardians of 102353 children 0 to 17 years old. Disparities in selected medical and oral health and health care measures were examined for white, African American, Latino, Asian/Pacific Islander, Native American, and multiracial children. Multivariate analyses were performed to adjust for primary language at home, age, insurance coverage, income, parental education and employment, and number of children and adults in the household. Forty measures of medical and oral health status, access to care, and use of services were analyzed. RESULTS. Many significant disparities were noted; for example, uninsurance rates were 6% for whites, 21% for Latinos, 15% for Native Americans, 7% for African Americans, and 4% for Asians or Pacific Islanders, and the proportions with a usual source of care were as follows: whites, 90%; Native Americans, 61%; Latinos, 68%; African Americans, 77%; and Asians or Pacific Islanders, 87%. Many disparities persisted for ≥1 minority group in multivariate analyses, including increased odds of suboptimal health status, overweight, asthma, activity limitations, behavioral and speech problems, emotional difficulties, uninsurance, suboptimal dental health, no usual source of care, unmet medical and dental needs, transportation barriers to care, problems getting specialty care, no medical or dental visit in the past year, emergency department visits, not receiving mental health care, and not receiving prescription medications. Certain disparities were particularly marked for specific racial/ethnic groups: for Latinos, suboptimal health status and teeth condition, uninsurance, and problems getting specialty care; for African Americans, asthma, behavior problems, skin allergies, speech problems, and unmet prescription needs; for Native Americans, hearing or vision problems, no usual source of care, emergency department visits, and unmet medical and dental needs; and for Asians or Pacific Islanders, problems getting specialty care and not seeing a doctor in the past year. Multiracial children also experienced many disparities. CONCLUSIONS. Minority children experience multiple disparities in medical and oral health, access to care, and use of services. Certain disparities are particularly marked for specific racial/ethnic groups, and multiracial children experience many disparities.

Heterogeneity of childhood asthma among hispanic children : Puerto rican children bear a disproportionate burden

OBJECTIVES. To estimate differences in asthma prevalence among Hispanic subgroups and non-Hispanic children living in the United States and to explore the association between these differences and risk factors. METHODS. Weighted logistic regression analyses of merged 1997 to 2001 National Health Interview Survey data were used to estimate the prevalence of asthma diagnosis and asthma attacks in a sample of 46511 children (age: 2–17 years) living in the 50 states and the District of Columbia. RESULTS. Puerto Rican children had the highest prevalence of lifetime asthma (26%) and recent asthma attacks (12%), compared with non-Hispanic black children (16% and 7%, respectively), non-Hispanic white children (13% and 6%, respectively), and Mexican children (10% and 4%, respectively). Adjustment for asthma risk factors did not change these comparisons appreciably. Compared with non-Hispanic white children, the adjusted odds ratios (ORs) for a lifetime asthma diagnosis were 2.33 (95% confidence interval [CI]: 1.90–2.84) for Puerto Rican children, 1.16 (95% CI: 1.04–1.29) for non-Hispanic black children, and 0.90 (95% CI: 0.79–1.03) for Mexican children. Birthplace influenced the association between ethnicity and lifetime asthma diagnosis differently for Puerto Rican and Mexican children. Compared with United States-born non-Hispanic white children with United States-born parents, the adjusted ORs were 1.95 (95% CI: 1.48–2.57) for Puerto Rican children in families with the child and parent(s) born in the 50 states/District of Columbia and 2.50 (95% CI: 1.51–4.13) for island-born Puerto Rican children with island-born parents. The corresponding adjusted ORs for Mexican children were 1.05 (95% CI: 0.90–1.22) for families born in the 50 states/District of Columbia and 0.43 (95% CI: 0.29–0.64) for those born in Mexico. The results were similar for recent asthma attacks. CONCLUSIONS. The appreciably higher asthma morbidity rates experienced by Puerto Rican children cannot be explained by sociodemographic and other risk factors measured in the National Health Interview Survey. The heterogeneity of asthma among Hispanic subgroups should be considered in developing effective public health prevention and intervention strategies.

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

OBJECTIVE: This technical report reviews and synthesizes the published literature on racial/ethnic disparities in childrens 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 childrens 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 childrens 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.

The impact of ethnicity, family income, and parental education on children's health and use of health services.

OBJECTIVES This study characterized ethnic disparities for children in demographics, health status, and use of services; explored whether ethnic subgroups (Puerto Rican, Cuban, and Mexican) have additional distinctive differences; and determined whether disparities are explained by differences in family income and parental education. METHODS Bivariate and multivariate analyses of data on 99,268 children from the 1989-91 National Health Interview Surveys were conducted. RESULTS Native American, Black, and Hispanic children are poorest (35%, 41% below poverty level vs 10% of Whites), least healthy (66%-74% in excellent or very good health vs 85% of Whites), and have the least well educated parents. Compared with Whites, non-White children average fewer doctor visits and are more likely to have excessive intervals between visits. Hispanic subgroup differences in demographics, health, and use of services equal or surpass differences among major ethnic groups. In multivariate analyses, almost all ethnic group disparities persisted after adjustment for family income, parental education, and other relevant covariates. CONCLUSIONS Major ethnic groups and subgroups of children differ strikingly in demographics, health, and use of services; subgroup differences are easily overlooked; and most disparities persist even after adjustment for family income and parental education.

Iron deficiency in early childhood in the United States: Risk factors and racial/ethnic disparities

BACKGROUND. Iron deficiency affects 2.4 million US children, and childhood iron-deficiency anemia is associated with behavioral and cognitive delays. Given the detrimental long-term effects and high prevalence of iron deficiency, its prevention in early childhood is an important public health issue. OBJECTIVES. The study objectives were to (1) identify risk factors for iron deficiency in US children 1 to 3 years old, using data from the most recent waves of the National Health and Nutrition Examination Survey IV (1999–2002) and (2) examine risk factors for iron deficiency among Hispanic toddlers, the largest minority group of US children. PATIENTS AND METHODS. Analyses of the National Health and Nutrition Examination Survey IV were performed for a nationally representative sample of US children 1 to 3 years old. Iron-status measures were transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Bivariate and multivariable analyses were performed to identify factors associated with iron deficiency. RESULTS. Among 1641 toddlers, 42% were Hispanic, 28% were white, and 25% were black. The iron deficiency prevalence was 12% among Hispanics versus 6% in whites and 6% in blacks. Iron deficiency prevalence was 20% among those with overweight, 8% for those at risk for overweight, and 7% for normal-weight toddlers. Fourteen percent of toddlers with parents interviewed in a non–English language had iron deficiency versus 7% of toddlers with parents interviewed in English. Five percent of toddlers in day care and 10% of the toddlers not in day care had iron deficiency. Hispanic toddlers were significantly more likely than white and black toddlers to be overweight (16% vs 5% vs 4%) and not in day care (70% vs 50% vs 43%). In multivariable analyses, overweight toddlers and those not in day care had higher odds of iron deficiency. CONCLUSIONS. Toddlers who are overweight and not in day care are at high risk for iron deficiency. Hispanic toddlers are more likely than white and black toddlers to be overweight and not in day care. The higher prevalence of these risk factors among Hispanic toddlers may account for their increased prevalence of iron deficiency.

Satisfaction With Care and Ease of Using Health Care Services Among Parents of Children With Special Health Care Needs: The Roles of Race/Ethnicity, Insurance, Language, and Adequacy of Family-Centered Care

OBJECTIVES. To examine whether racial/ethnic disparities exist in parental reports of satisfaction with care and ease of using health care services among children with special health care needs (CSHCN) and to identify factors associated independently with satisfaction with care and ease of use of health care services among CSHCN. METHODS. We analyzed data for 38886 CSHCN <18 years of age in the National Survey of CSHCN, conducted from 2000 to 2002. Outcome variables included perceived satisfaction with care and ease of service use. Covariates included sociodemographic factors, insurance, interview language, condition severity and stability, adequacy of family-centered care measures, and having a personal doctor/nurse. RESULTS. The prevalences of reported dissatisfaction with care and problems with ease of using services among parents of CSHCN were 8% and 25%, respectively. Black and Hispanic parents were significantly more likely than white parents to be dissatisfied with care (13% and 16% vs 7%) and to report problems with ease of service use (35% and 34% vs 23%). Hispanic/white disparities in satisfaction with care and ease of use of services disappeared only after multivariate adjustment for parental interview language. Black/white disparities in satisfaction with care disappeared after adjustments for adequacy of family-centered care measures, but black/white disparities in ease of using services persisted. The severity of the child’s condition, lack of insurance, parental interview in Spanish, and inadequate family-centered care were associated significantly with dissatisfaction with care and problems with ease of using health care services. CONCLUSIONS. Policies and strategies that reduce language barriers, promote insurance coverage and family-centered care, and improve ease of use of services among minority CSHCN have the potential to reduce racial/ethnic disparities in satisfaction with care and to promote ease of use of services among families with CSHCN.

Limited English Proficiency, Primary Language at Home, and Disparities in Children's Health Care: How Language Barriers are Measured Matters

Background. Approximately 3.5 million U.S. schoolchildren are limited in English proficiency (LEP). Disparities in childrens health and health care are associated with both LEP and speaking a language other than English at home, but prior research has not examined which of these two measures of language barriers is most useful in examining health care disparities. Objectives. Our objectives were to compare primary language spoken at home vs. parental LEP and their associations with health status, access to care, and use of health services in children. Methods. We surveyed parents at urban community sites in Boston, asking 74 questions on childrens health status, access to health care, and use of health services. Results. Some 98% of the 1,100 participating children and families were of non-white race/ethnicity, 72% of parents were LEP, and 13 different primary languages were spoken at home. “Dose-response” relationships were observed between parental English proficiency and several child and parental sociodemographic features, including childrens insurance coverage, parental educational attainment, citizenship and employment, and family income. Similar “dose-response” relationships were noted between the primary language spoken at home and many but not all of the same sociodemographic features. In multivariate analyses, LEP parents were associated with triple the odds of a child having fair/poor health status, double the odds of the child spending at least one day in bed for illness in the past year, and significantly greater odds of children not being brought in for needed medical care for six of nine access barriers to care. None of these findings were observed in analyses of the primary language spoken at home. Individual parental LEP categories were associated with different risks of adverse health status and outcomes. Conclusions. Parental LEP is superior to the primary language spoken at home as a measure of the impact of language barriers on childrens health and health care. Individual parental LEP categories are associated with different risks of adverse outcomes in childrens health and health care. Consistent data collection on parental English proficiency and referral of LEP parents to English classes by pediatric providers have the potential to contribute toward reduction and elimination of health care disparities for children of LEP parents.

Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters.

STUDY OBJECTIVE To compare interpreter errors and their potential consequences in encounters with professional versus ad hoc versus no interpreters. METHODS This was a cross-sectional error analysis of audiotaped emergency department (ED) visits during 30 months in the 2 largest pediatric EDs in Massachusetts. Participants were Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters. Outcome measures included interpreter error numbers, types, and potential consequences. RESULTS The 57 encounters included 20 with professional interpreters, 27 with ad hoc interpreters, and 10 with no interpreters; 1,884 interpreter errors were noted, and 18% had potential clinical consequences. The proportion of errors of potential consequence was significantly lower for professional (12%) versus ad hoc (22%) versus no interpreters (20%). Among professional interpreters, previous hours of interpreter training, but not years of experience, were significantly associated with error numbers, types, and potential consequences. The median errors by professional interpreters with greater than or equal to 100 hours of training was significantly lower, at 12, versus 33 for those with fewer than 100 hours of training. Those with greater than or equal to 100 hours of training committed significantly lower proportions of errors of potential consequence overall (2% versus 12%) and in every error category. CONCLUSION Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters. Among professional interpreters, hours of previous training, but not years of experience, are associated with error numbers, types, and consequences. These findings suggest that requiring at least 100 hours of training for interpreters might have a major impact on reducing interpreter errors and their consequences in health care while improving quality and patient safety.

The Language Spoken at Home and Disparities in Medical and Dental Health, Access to Care, and Use of Services in US Children

BACKGROUND AND OBJECTIVE. Fifty-five million Americans speak a non-English primary language at home, but little is known about health disparities for children in non-English-primary-language households. Our study objective was to examine whether disparities in medical and dental health, access to care, and use of services exist for children in non-English-primary-language households. METHODS. The National Survey of Childhood Health was a telephone survey in 2003–2004 of a nationwide sample of parents of 102 353 children 0 to 17 years old. Disparities in medical and oral health and health care were examined for children in a non-English-primary-language household compared with children in English- primary-language households, both in bivariate analyses and in multivariable analyses that adjusted for 8 covariates (childs age, race/ethnicity, and medical or dental insurance coverage, caregivers highest educational attainment and employment status, number of children and adults in the household, and poverty status). RESULTS. Children in non-English-primary-language households were significantly more likely than children in English-primary-language households to be poor (42% vs 13%) and Latino or Asian/Pacific Islander. Significantly higher proportions of children in non-English-primary-language households were not in excellent/very good health (43% vs 12%), were overweight/at risk for overweight (48% vs 39%), had teeth in fair/poor condition (27% vs 7%), and were uninsured (27% vs 6%), sporadically insured (20% vs 10%), and lacked dental insurance (39% vs 20%). Children in non-English-primary-language households more often had no usual source of medical care (38% vs 13%), made no medical (27% vs 12%) or preventive dental (14% vs 6%) visits in the previous year, and had problems obtaining specialty care (40% vs 23%). Latino and Asian children in non-English-primary-language households had several unique disparities compared with white children in non-English-primary-language households. Almost all disparities persisted in multivariable analyses. CONCLUSIONS. Compared with children in English-primary-language households, children in non-English-primary-language households experienced multiple disparities in medical and oral health, access to care, and use of services.

Prevalence of Vitamin D Deficiency Among Overweight and Obese US Children

OBJECTIVE: Adequate vitamin D is essential for skeletal health in developing children. Although excess body weight is associated with risk of vitamin D deficiency, the national prevalence of and risk factors associated with vitamin D deficiency in overweight and obese children are unknown. METHODS: The prevalence of vitamin D deficiency (defined as 25-hydroxyvitamin-D <20 ng/mL) was determined in a sample of 6- to 18-year-old children who were enrolled in a cross-sectional study (the 2003–2006 National Health and Nutrition Examination Survey) in which body weight and height were measured directly. Children were classified as healthy-weight, overweight, obese, or severely obese by using recommended age- and gender-specificBMI-percentile cut points. Associations between BMI-percentile classification and vitamin D deficiency were examined after adjustment for relevant confounders. Sample weights were used to generate nationally representative estimates. RESULTS: The prevalence of vitamin D deficiency in healthy-weight, overweight, obese, and severely obese children was 21% (20%–22%), 29% (27%–31%), 34% (32%–36%), and 49% (45%–53%), respectively. The prevalence of vitamin D deficiency in severely obese white, Latino, and African-American children was 27% (3%–51%), 52% (36%–68%), and 87% (81%–93%), respectively. Compared with healthy-weight children, overweight, obese, and severely obese children had significantly greater adjusted odds of vitamin D deficiency. Modifiable factors associated with vitamin D deficiency in overweight/obese children were identified. CONCLUSIONS: Vitamin D deficiency is highly prevalent in overweight and obese children. The particularly high prevalence in severely obese and minority children suggests that targeted screening and treatment guidance is needed.