1. 1 Unequal Treatment for Young Children? Racial and Ethnic Disparities in Early Childhood Health and Healthcare Glenn Flores, MD, 1 Sandy Tomany, MS 1 and Lynn Olson, PhD 2 1 Department of Pediatrics, Medical College of Wisconsin and Childrens Hospital of Wisconsin; 2 Department of Practice & Research, American Academy of Pediatrics Funding: Robert Wood Johnson Foundation, AHRQ, Gerber Foundation

2. 2 Background l US experiencing demographic surge in minority children, particularly among youngest age groups l By 2030 u There will be more minority children than non-Hispanic white children 0-18 years old u Among 0-5 year olds, minorities will outnumber non-Hispanic whites by 1.1 million l As number and proportion of minority children grow, racial/ethnic disparities will take on even greater importance for pediatric providers

3. 3 Background l 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 l Although multiple studies document racial/ethnic disparities in adults, few studies have examined such disparities in children u For example, only 5 of 103 studies in IOMs extensive literature review specifically addressed disparities in children l In particular, little known about whether younger children experience racial/ethnic disparities in healthcare

4. 4 Study Aim l To examine racial/ethnic disparities in early childhood health and healthcare using nationally representative sample

5. 5 Methods: Data Source- National Survey of Early Childhood Health (NSECH) l Telephone survey in 2000 of national random sample of households with children 4-35 months old l Oversampled households with black and Hispanic children l Parent or guardian most responsible for childs healthcare interviewed l 2,068 interviews completed l Interview completion rate = 79% l Estimates based on sampling weights generalize to entire US population of children 4-35 months of age

6. 6 Methods: Study Variables l Variables examined included u Selected sociodemographics u Healthcare provider characteristics u Use of health services u Parental satisfaction with care u Topics discussed with parents by providers l Childrens race/ethnicity defined as white, black, or Hispanic by parental report ( black and Hispanic = NSECH terms) l Because of insufficient sample sizes, subjects from other racial/ethnic groups excluded

7. 7 Methods: Statistical Analysis l Multivariable analyses performed to examine racial/ethnic differences after adjustment for u Insurance coverage u Survey language chosen by parent (English vs. Spanish) u Health status u Poverty u Childs age u Parental educational attainment

8. 8 Characteristics: 4-35 Month-Old US Children in 2000 (NSECH) Characteristic White (N = 718) Black (N = 477) Hispanic (N = 817) P Mean age (mo)19.5 18.70.22 Male sex (%)5348510.34 Mother not high school grad (%)112649<.001 Mother married (%)813258<.001 Mother not employed (%)453953<.001 Family income at/below poverty level (%) 134948<.001 Uninsured (%) Private insurance (%) Public insurance (%) 9 72 19 18 32 50 31 29 40 <.001 Childs health excellent/very good (%)907972<.001

9. 9 Characteristics: Well Child Care Providers for 4-35 Month-Old US Children Characteristic White (N = 718) Black (N = 477) Hispanic (N = 817) P Usual medical care in private practice80%68% 58%<.001 No specific well child care provider52%61%63%<.001 Well child provider assigned to child7%14%19%.01 Urban provider practice location50%66%76%<.001 Well child care provider male63% 51%56%.03

10. 10 Parental Satisfaction and Interactions with Well Child Care Providers: 4-35 Month-Old US Children Provider Characteristic White (N = 718) Black (N = 477) Hispanic (N = 817) P Never/only sometimes took time to understand childs 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

11. 11 Topics Discussed with Parent by Well Child Care Providers: 4-35 Month-Old US Children Topic White (N = 718) Black (N = 477) Hispanic (N = 817) P Violence in community6%14%20%<.001 Smoking in household72%86%85%<.001 Alcohol or drug use in household35%58%65%<.001 Trouble paying for childs needs10%18%14%.001 Spouse/partner supports parenting style34%46% <.001 Told parent developmental assessment done 47%34%43%.001 Immunizations97%96%94%.16 Food/feeding issues83% 85%.78 Car seats69%77%.001 Importance of reading to child59%69%64%.006

12. 12 Use of Selected Health Services: 4-35 Month-Old US Children Measure White (N = 718) Black (N = 477) Hispanic (N = 817) P Made age-appropriate # of well-child care visits (by AAP guidelines) 68%70%66%.55 Mean number of phone calls to doctors office in past year 4.23.12.0<.001 1 or more ED visits in past year32%47%41%<.001 1 or more hospital stays in past year9%17%12%.005 Provider referred child to specialist 22%17%11%<.001

13. 13 Multivariate Analyses: Racial/Ethnic Disparities for 4-35 Month-Old US Children Odds Ratio (95% CI)* MeasureBlackHispanic Uninsured1.7 (1.02, 2.9)2.3 (1.4, 3.8) Childs health not excellent or very good2.1 (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 childs 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) Mean # of calls to doctors office in past year-1.1 (-1.8,-0.3)-1.0 (-1.8,-0.2) One or more ED visits in past year1.5 (1.1, 2.2)1.4 (0.96, 2.0) Child not referred to specialist by provider1.8 (1.1, 2.9)1.7 (1.1, 2.8) *Reference group: white children

14. 14 Multivariate Analyses: Racial/Ethnic Disparities for 4-35 Month-Old US Children Odds Ratio (95% CI)* Topic Discussed with Parent by ProviderBlackHispanic Violence in community2.2 (1.1, 4.4)2.3 (1.2, 4.4) Smoking in household1.9 (1.2, 2.8)1.5 (0.9, 2.3) Use of alcohol or drugs in household2.0 (1.4, 2.8)1.6 (1.1, 2.3) Trouble paying for childs needs1.7 (1.03, 2.8)1.3 (0.8, 2.1) Spouse/partner supports parenting efforts1.6 (1.2, 2.3)1.4 (1.0, 2.1) Childcare arrangements2.0 (1.4, 2.8)1.3 (0.9, 1.9) Importance of reading to child1.6 (1.1, 2.3)1.2 (0.8, 1.7) *Reference group: white children

15. 15 Multivariate Analyses: Parent Survey Language Disparities for 4-35 Month-Old US Children Measure Odds Ratio (95% CI) Parent Survey in Spanish* Uninsured 1.9 (1.2, 2.9) Childs health not excellent or very good 2.8 (1.7, 4.6) Usual place for medical care not private/group practice 2.5 (1.6, 3.9) Provider never/sometimes understands childs needs 1.9 (1.2, 3.2) Provider discussed violence in community 2.3 (1.4, 3.7) Provider discussed use of alcohol or drugs in household 2.8 (1.8, 4.4) Parent told developmental assessment done by provider 2.2 (1.4, 3.4) Mean # of calls to doctors office in past year -2.0 (-2.8, -1.2) Child not referred to specialist by provider 2.7 (1.4, 5.2) *Reference group: parent completed survey in English

16. 16 Conclusions Young minority children in US and those with Spanish-speaking parents experience multiple disparities in l Insurance coverage l Health status l Parental satisfaction with well-child care providers l Provider understanding of childs needs and parents childrearing preferences l Provider discussion of violence and alcohol/illicit drug use l Parents calls to doctors offices l Specialty referrals

17. 17 Implications l Greater insight needed about why such racial/ethnic disparities exist l 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 l Targeted educational interventions, such as cultural competency training, might help ensure equal treatment for all young children in pediatric visits