Children are affected by widespread disparities in health status and in the quality of the health care they receive. Given the increasing number of minority children in the U.S., research on these disparities is very important. Paying heed to the inequalities in child health research, however, is easier said than done.
In their commentary "Child Health Disparities: Framing a Research Agenda" (Ambulatory Pediatrics, July/Aug. 2004), Ivor Braden Horn of the Children's National Medical Center and Anne C. Beal of The Commonwealth Fund suggest a research framework for identifying health disparities, determining their root causes, and developing effective interventions by researching disparities at the individual, health system, community, and societal levels. By monitoring and reevaluating these interventions, disparities in health care and health status can be reduced, the authors say.
According to Horn and Beal, the time is ripe for such a research agenda. Current census pro-jections estimate that by the year 2050, the majority of Americans will belong to racial and ethnic minority groups. This shift will be even more pronounced in the pediatric population, with some parts of the country already reporting a pediatric demography marked by a "majority minority."
Identifying Health Disparities
"Disparity" in health care can have many meanings. For the researchers, equity in health is an issue of ethical and social justice. The ultimate goal of child health disparities research is achieving equity in health care, with a keen focus on the efforts needed to achieve equity.
The authors' research agenda seeks to reduce health inequities that arise from diminished social privilege. The lower social status of minority parents relative to white parents partially determines racial differences in infant mortality rates, which affects the health outcomes of their infants. In short, to fully address racial differences in infant mortality, researchers must consider the social inequalities that lead to those health disparities.
When developing a research plan, it is important to define and label disparities. For example, medical errors may be more common because a minority child's parents do not speak English. More work should be done on the prevalence of this problem, and on the types of medical errors that result from poor communication.
Children have different patterns of disease and wellness than adults, and the study of child health disparities takes into account these unique characteristics. Children go through rapid developmental changes, for example, and also are dependent on others for access to health care. Children usually are healthy, so disparities research emphasizes inequities in preventive care, such as vaccination rates.
Finally, there are demographic patterns to consider. Children are more likely than any other segment of the population to live in poverty. They are frequently insured through public programs like Medicaid and SCHIP. Recent estimates suggest that more than 40 per cent of African American and one-third of Hispanic children have public insurance. This presents an opportunity for health plan-based quality improvements that can reduce disparities.
Identifying Root Causes of Disparities
Research on disparities should not merely adjust for race; it should examine all factors that may contribute to disparities and try to explain their root causes.
The agenda of child health disparities research is influenced by two important factors: cultural heritage and sociopolitical status. Culture—a shared system of values and behaviors—affects the disparities research framework because it influences every health care interaction. An inequitable health encounter happens when biases based on cultural differences enter into medical interactions. Sociopolitical status is a factor in the research framework because it affects the social determinants of health care, including housing, nutrition, environmental exposures, and the stressors prevalent in low-income communities. Any thorough examination of disparities must take into account sociopolitical status or it will miss an opportunity to develop a thorough understanding of equity in health care.
Eliminating disparities is more complex. The development of effective interventions must also occur at four levels: individual, health systems, community and societal.
Understanding Child Heath Disparities
Personal experiences with racism and racial discrimination shape how children and their caregivers view life. Chronic exposure to racism can have an impact on health. In a 2002 study cited by the authors, some African American women, for example, were two to three times more likely to have had a preterm infant if they had experienced discriminatory treatment in seeking housing or in societal interactions.
The research literature suggests that genetics does not play a major role in health disparities. Rather, the authors suggest that the racial distribution of access to high-quality, culturally-responsive care explains most of the racial variations in care.
There also are measurement issues to consider. How should researchers define race, for example, or take into account people of more than one race? Until there are agreed-upon standards, disparity researchers should detail how they measure race.
There is growing recognition of disparities in the care children of color receive. If researchers can address these inequities, the health care and health status of all children are likely to improve.
Facts and Figures
- The African American infant mortality rate is 2.5 times higher than the white rate, and minority children with asthma are 40 percent to 100 percent more likely to be hospitalized.
- Recent estimates suggest that more than 40 percent of African American and one-third of Hispanic children have public insurance such as Medicaid or SCHIP.
- According to the 2002 Census, 16.7 percent of children live in poverty; more children are poor than any other segment of the population.