Content uploaded by Glenn Flores
Author content
All content in this area was uploaded by Glenn Flores
Content may be subject to copyright.
DOI: 10.1542/peds.2007-1243
2008;121;e286-e298; originally published online Jan 14, 2008; Pediatrics
Glenn Flores and Sandra C. Tomany-Korman
Use of Services in US Children
Racial and Ethnic Disparities in Medical and Dental Health, Access to Care, and
http://www.pediatrics.org/cgi/content/full/121/2/e286
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Grove Village, Illinois, 60007. Copyright © 2008 by the American Academy of Pediatrics. All
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
by on May 17, 2008 www.pediatrics.orgDownloaded from
ARTICLE
Racial and Ethnic Disparities in Medical and Dental
Health, Access to Care, and Use of Services in
US Children
Glenn Flores, MD
a,b
, Sandra C. Tomany-Korman, MS
c
a
Division of General Pediatrics, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas;
b
Department of Pediatric Medicine, Children’s
Medical Center, Dallas, Texas;
c
Signature Science, LLC, Austin, Texas
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
BACKGROUND. Not enough is known about the national prevalence of racial/ethnic
disparities in children’s 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 Children’s Health was a telephone survey in 2003–
2004 of a national random sample of parents and guardians of 102 353 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 Amer-
icans, 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
ⱖ1 minority group in multivariate analyses, including increased odds of suboptimal
health status, overweight, asthma, activity limitations, behavioral and speech prob-
lems, 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 depart-
ment visits, not receiving mental health care, and not receiving prescription medi-
cations. 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 aller-
gies, 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.
www.pediatrics.org/cgi/doi/10.1542/
peds.2007-1243
doi:10.1542/peds.2007-1243
This work was presented in part at the annual
meetings of the Pediatric Academic Societies,
April 30, 2006, San Francisco, CA; Academy
Health, June 26, 2006, Seattle, WA; and
American Public Health Association,
November 7, 2006, Boston, MA.
Key Words
disparities, minorities, children, race,
ethnicity, African Americans, Hispanics,
Asians/Pacific Islanders, Native Americans,
multiracial
Abbreviations
NSCH—National Survey of Children’s
Health
OARO— overweight or at risk for
overweight
ED— emergency department
ADHD—attention-deficit/hyperactivity
disorder
NHANES—National Health and Nutrition
Examination Survey
Accepted for publication Jun 18, 2007
Address correspondence to Glenn Flores, MD,
Division of General Pediatrics, Department of
Pediatrics, University of Texas Southwestern
Medical Center, 5323 Harry Hines Blvd, Dallas,
TX 75390. E-mail: glenn.flores@utsouthwestern.
edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2008 by the
American Academy of Pediatrics
e286 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
A
LTHOUGH INCREASING ATTENTION is being paid to
racial/ethnic disparities in health and health care,
very little of the attention is directed toward children.
For example, in a recent report on disparities by the
Agency for Healthcare Research and Quality,
1
there
were ⬎3 times as many disparity measures for adults as
there were for children and only 15% of measures were
child specific, and in the Institute of Medicine’s compre-
hensive health disparities monograph, only 5% of stud-
ies addressed disparities in children.
2
There has been no
published comprehensive analysis (to our knowledge) of
racial/ethnic disparities in medical and dental health,
access to care, and use of services in US children. The
study aim, therefore, was to perform such an analysis,
using a large, nationally representative database that
provides the opportunity to examine child health dispar-
ities for all 5 of the major US racial/ethnic groups, as well
as multiracial children.
METHODS
Data Source
The data source was the National Survey of Children’s
Health (NSCH), a module of the State and Local Area
Integrated Telephone Survey conducted by the Centers
for Disease Control and Prevention’s National Center for
Health Statistics. A detailed description of the design,
methods, and operation of the NSCH is provided else-
where.
3
Herein, a brief summary is provided of methods
relevant to this analysis.
The NSCH was designed to produce national and
state-specific prevalence estimates for a variety of phys-
ical, emotional, and behavioral health indicators and
measures of children’s health care experiences.
3
A ran-
dom-digit-dial sample was selected of households with
children under 18 years old from each of the 50 states
and the District of Columbia. One child was randomly
selected from all of the children in each household as the
subject of the survey. The parent or guardian who knew
the most about the child’s health and health care served
as the survey respondent. NSCH interviews were admin-
istered in Spanish and English.
A total of 102 353 NSCH interviews were completed
from January 2003 to July 2004. The weighted, overall
Council of American Survey Research Organizations re-
sponse rate was 55.3%. Estimates based on sampling
weights generalize to the noninstitutionalized popula-
tion of children nationwide (including for each racial/
ethnic group, given that the NSCH is a random-digit-dial
sample of households with children from each of the 50
states and the District of Columbia).
3
The sampling
weights also adjust for households with multiple tele-
phone lines and provide multiple adjustments for non-
response bias, including for unknown household status
and eligibility, households with multiple children, and
noncoverage of households without telephones.
Analyses
Data were coded and analyzed by using Stata 8 (Stata
Corp, College Station, TX).
4
For all of the variables,
responses of “don’t know” or “refused to answer” were
set to missing.
Children’s race/ethnicity was classified as white, black/
African American (hereafter referred to as African Ameri-
can), Latino or Hispanic (hereafter referred to as Latino),
Asian/Pacific Islander, Native American, and multiracial on
the basis of parental response. Other demographic vari-
ables examined included the child’s age and insurance
coverage, the number of children and adults in the house-
hold, highest educational attainment in the household,
household employment status, and combined annual fam-
ily income. The child’s insurance coverage was classified as
uninsured or publicly or privately insured on the basis of
the coverage at the time that the survey was administered.
Highest household educational attainment was dichoto-
mized as high school graduate or greater versus not a high
school graduate. Household employment was coded affir-
matively if anyone in the household was employed for
ⱖ50 weeks in the previous year. Household income was
defined as below the poverty threshold versus at or above
the threshold on the basis of the family size and federal
thresholds at the time of the survey.
The following dependent variables with multiple re-
sponse categories were transformed into dichotomous
variables: child’s health status excellent or very good
versus not excellent or very good (eg, good, fair, or poor,
consistent with previous research
5
); child’s BMI over-
weight or at risk for overweight (OARO; ⱖ85th percen-
tile for age and gender) versus not OARO; teeth condi-
tion excellent or very good versus not excellent or very
good (eg, good, fair, or poor); ⬎ vs ⱕ1 year since last
dental visit; child has versus has not seen physician in
past year; child did versus did not receive all of the
needed medical or dental care (if child received care);
the child had no versus ⱖ1 visit to the emergency de-
partment (ED) in the past year; the child did versus did
not receive preventative dental care in past year; the
child was versus was not given prescription in last year;
and the child needed but did versus did not receive a
prescription in last year.
Variance estimation techniques were used with Stata
to adjust for the complex survey design of the NSCH.
Pearson’s
2
test statistic was used to test for indepen-
dence between race/ethnicity and discrete factors. To
account for the complex survey design, the statistic was
turned into an F statistic with noninteger degrees of
freedom using a second-order Rao and Scott correction.
The t statistic from linear regression, with degrees of
freedom equal to the total number of primary sampling
units minus the total number of strata, was used to
identify racial or ethnic disparities in means of continu-
ous factors. The t statistic also was used to test for the
significance of factors included in multivariable linear
and logistic regression models.
RESULTS
Sociodemographics
There were slight differences in the mean age of the
various racial/ethnic groups of children (Table 1), with
Latino and multiracial children ⬃1 year younger in
PEDIATRICS Volume 121, Number 2, February 2008 e287
by on May 17, 2008 www.pediatrics.orgDownloaded from
mean age than white children but no significant differ-
ences in the proportion of boys. There were substantial
differences in the highest educational attainment in the
household, with 29% of Latino children’s households
with no high school graduate, compared with 8% in
African American, 7% in Native American, 4% in mul-
tiracial, 3% in Asian/Pacific Islander, and 2% in white
children’s households. Conversely, 91% of Asian/Pacific
Islander children’s households had a member who has
attended at least some college, compared with three
fourths of white, 73% of multiracial, 57% of African
American, and 37% of Latino children’s households.
The primary language spoken at home was far more
likely not be English in Latino (60%), Asian/Pacific Is-
lander (41%), and Native American (8%) households
compared with white (1%) and multiracial (1%) chil-
dren’s households.
Native American, Latino, and African American fam-
ilies were significantly more likely to have ⬎3 children
in the household compared with white and multiracial
families (Table 1). Approximately one fourth of Latino,
Native American, and Asian/Pacific Islander and ⬃20%
of African American and multiracial families had ⬎2
adults in the children’s household compared with 16%
of white households. White children’s households
(93%) were most likely to have an adult employed in
the household for ⱖ50 weeks in the past year, whereas
Native American (83%), African American (84%), and
Latino (85%) households were least likely.
The combined annual family income was ⬍100% of the
federal poverty threshold in more than one third of Native
American and Latino children’s households, approxi-
mately one third of African American children’s house-
holds, and 17% of multiracial families, compared with only
9% of Asian/Pacific Islander and 8% of white children’s
households. Conversely, ⬃40% of Asian/Pacific Islander
and one third of white children’s households have com-
bined family incomes of ⱖ400% of the federal poverty
threshold compared with 27% of multiracial, 8% of Latino,
and 6% of Native American children’s households.
Medical and Oral Health Status
Approximately 90% of white, Asian/Pacific Islander,
multiracial, and Native American children were in ex-
cellent or very good health status compared with only
79% of African American and 65% of Latino children
(Table 2). Conversely, Latino children (8%) were most
likely and Asian/Pacific Islander children least likely
(0.3%) to be in poor or fair health. Approximately one
third of African American, Native American, and Latino
children were overweight compared with 21% to 25%
of children in other racial or ethnic groups. Approxi-
mately 55% of Native American, 52% of African Amer-
ican, and 47% of Latino children were OARO compared
TABLE 1 Selected Sociodemographic Features of US Children 0 to 17 Years old (N ⴝ 102 353) According to Race/Ethnicity
Characteristic Mean or Proportion for Each Racial/Ethnic Group P
White Latino African
American
Asian/Pacific
Islander
Native
American
Multiracial
Mean age, y 8.8 7.9 8.9 8.3 8.8 7.9 ⬍.0001
Male gender, % 51.3 51.7 50.2 49.0 54.9 50.0 .62
Highest educational attainment in
household, %
⬍.0001
Not a high school graduate 2.3 28.5 7.7 2.8 6.7 4.1
High school graduate 22.9 34.9 35.5 5.9 35.1 22.7
At least some college 74.9 36.6 56.8 91.3 58.2 73.1
Primary language spoken at home not
English, %
0.9 59.5 1.2 41.3 7.7 0.7 ⬍.0001
No. of children in household, % ⬍.0001
1 22.5 16.4 22.9 28.7 18.9 28.0
2 41.7 32.6 33.8 35.9 31.3 40.6
3 23.9 29.8 25.1 27.1 23.8 21.0
⬎3 11.9 21.3 18.2 8.3 26.0 10.4
No. of adults in household, % ⬍.0001
1 10.4 12.9 33.1 10.5 17.3 20.1
2 74.2 58.7 47.5 64.6 56.8 60.8
⬎2 15.5 28.5 19.4 24.9 25.9 19.2
Adult in household employed ⱖ50 wk
in past year
92.7 85.2 83.7 89.7 82.7 88.6 ⬍.0001
Combined family income, % of federal
poverty threshold
⬍.0001
⬍100 7.9 35.0 28.8 8.6 35.7 16.8
100–199 17.8 26.6 27.2 18.1 28.9 20.8
200–299 18.6 10.4 13.1 9.1 17.9 14.5
300–399 17.2 6.0 9.3 17.1 6.8 12.9
ⱖ400 31.4 7.9 12.1 39.7 5.8 27.1
Unknown 7.1 14.1 9.5 7.5 4.8 7.9
Data source: the NSCH.
e288 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
with 40% of multiracial and only approximately one
third of white and Asian/Pacific Islander children.
A need for more medical care than others was highest
among Native American and multiracial children and
lowest in Asian/Pacific Islander children (Table 2). The
prevalence of limited abilities is significantly higher
among African American, Native American, and multi-
racial children, and special therapy need or receipt was
by far the greatest among Native Americans (11%). Ap-
proximately one fourth of African American, multira-
cial, and Native American children had difficulty with
emotions, concentration, behavior, or interpersonal re-
lations, significantly higher than the other racial or eth-
nic groups, particularly Asians/Pacific Islanders (10%).
The prevalence of emotional developmental or behav-
ioral problems needing treatment or counseling, how-
ever, differed little among racial/ethnic groups, except
for the significantly lower prevalence among Asians/
Pacific Islanders. Learning disabilities were particularly
prevalent among Native Americans (13%) but rare
among Asians/Pacific Islanders.
Disparities were observed for a variety of specific child-
hood conditions (Table 2). Asthma was significantly more
prevalent among African American (18%), multiracial
(15%), and Native American (14%) children compared
with the other racial/ethnic groups (11%–12% preva-
TABLE 2 Medical and Oral Health Status of US Children 0 to 17 Years Old (N ⴝ 102 353) According to Race/Ethnicity
Health Status Characteristic Mean or Proportion for Each Racial/Ethnic Group P
White Latino African
American
Asian/Pacific
Islander
Native
American
Multiracial
Health status, %
a
⬍.0001
Excellent 68.7 41.8 52.4 59.9 55.0 62.5
Very good 22.1 23.5 26.7 28.0 30.8 24.8
Good 7.7 26.5 16.7 11.8 11.0 10.4
Fair 1.3 7.6 3.6 0.3 2.7 2.0
Poor 0.2 0.6 0.7 0.0 0.5 0.3
BMI class, % ⬍.0001
Underweight 7.4 7.5 6.9 12.7 4.2 7.3
Normal 57.4 45.8 41.6 52.2 40.4 52.5
At risk of overweight
b
14.7 16.1 14.6 13.0 21.0 15.3
Overweight
c
20.6 30.7 36.9 22.0 34.4 24.9
Needs more medical care than others, % 11.9 9.5 11.7 4.5 13.9 13.6 ⬍.0001
Has limited abilities, % 5.1 4.3 8.6 5.3 8.4 7.2 ⬍.0001
Needs/gets special therapy, %
d
6.3 5.7 6.9 2.0 11.2 7.2 .0004
Difficulty with emotions, concentration, behavior,
or interpersonal relations, %
17.0 15.4 24.6 9.7 21.8 23.9 ⬍.0001
Emotional, developmental, or behavioral problems
needing treatment or counseling, %
6.4 6.1 7.7 1.3 6.4 7.7 .0001
Learning disability, % 9.6 9.9 11.0 1.9 12.8 10.9 .0001
Asthma, % 11.5 11.0 18.2 11.9 14.2 15.1 .0001
Hearing or vision problems, % 2.9 3.0 1.9 2.0 5.8 2.9 .15
ADHD, % 8.0 3.3 7.2 1.8 7.1 8.5 .0001
Depression or anxiety, % 4.7 3.6 3.2 0.7 5.5 5.5 .0001
Behavior problems, % 4.9 4.8 8.2 0.6 4.5 6.9 .0001
Bone, joint, or muscle problems, % 3.4 2.5 3.3 0.7 2.7 4.1 .0001
Diabetes, % 0.4 0.2 0.2 0.1 1.0 0.3 .04
Developmental delay, % 4.0 2.0 3.2 0.7 4.6 4.7 .0001
Allergies, %
Respiratory 16.5 9.8 15.6 10.6 14.7 18.1 .0001
Digestive 3.6 3.2 3.7 3.6 3.2 5.9 .01
Skin 9.2 7.5 14.6 8.9 12.0 14.3 .0001
Headaches, % 5.4 5.4 7.2 2.7 8.7 6.5 .03
Speech problems, % 3.2 3.5 5.1 2.1 5.3 4.2 .0002
ⱖ3 ear infections in last 12 mo, % 5.0 5.1 4.1 1.8 5.2 5.6 .10
Teeth condition, %
a
⬍.0001
Excellent 49.4 26.9 34.4 33.6 36.0 43.8
Very good 27.1 20.5 26.8 34.8 30.6 26.2
Good 17.6 31.4 27.7 23.3 22.3 20.9
Fair 4.6 16.6 8.8 5.9 7.5 7.5
Poor 1.3 4.6 2.4 2.5 3.6 1.7
a
Data are by parental report.
b
BMI is 85% to 94% for age and gender.
c
BMI is ⱖ95% for age and gender.
d
Data include physical, occupational, or speech therapy.
Data source: the NSCH.
PEDIATRICS Volume 121, Number 2, February 2008 e289
by on May 17, 2008 www.pediatrics.orgDownloaded from
lence). Native American children had a significantly higher
prevalence of hearing or vision problems and diabetes.
Rates of attention-deficit/hyperactivity disorder (ADHD)
and respiratory allergies differed little among racial/ethnic
groups, except for significantly lower rates among Latino
and Asian/Pacific Islander children. Rates of depression or
anxiety; bone, joint, or muscle problems; and developmen-
tal delay were approximately equivalent, except for a sig-
nificantly lower prevalence for all 3 of the conditions
among Asians/Pacific Islanders. Behavior problems were
especially prevalent in African American (8%) and multi-
racial (7%) children and rare (0.6%) among Asians/ Pacific
Islanders. Digestive allergies occurred somewhat more fre-
quently among multiracial children, and skin allergy prev-
alence was significantly higher among African American,
multiracial, and Native American children. Headaches oc-
curred more often among African Americans and less often
among Asians/Pacific Islanders, and prevalence of speech
problems was somewhat greater among Native Americans
and African Americans. No significant racial or ethnic dif-
ferences were seen in the rates of ear infections.
Approximately three fourths of white, Asian/Pacific
Islander, and multiracial children’s teeth were in excel-
lent or very good condition compared with only approx-
imately two thirds of African American and Native
American children and about half of the Latino children
(Table 2). Poor or fair teeth condition was greatest in
Latino children (21%), with high rates (11%) also seen
in African American and Native American children.
Access to Medical and Dental Care
Latino (21%) and Native American (16%) children were
significantly more likely to be uninsured than African
American (7%), multiracial (7%), white (6%), and
Asian/Pacific Islander (3%) children (Table 3). Public
insurance coverage rates were greatest among Native
American, African American, and Latino children, and
private insurance coverage rates were significantly
higher in Asian/Pacific Islander (79%), white (76%),
and multiracial (63%) children. Sporadic insurance cov-
erage reached double digits among Native American,
Latino, African American, and multiracial children. Na-
tive American and Latino children were least likely to
have dental insurance, with approximately two thirds of
each group having dental coverage, compared with 78%
to 85% coverage rates in other racial/ethnic groups.
Although close to 90% of white, Asian/Pacific Is-
lander, and multiracial children had a regular source of
medical care, only 61% of Native American and 68% of
Latino children had a regular source of medical care
(Table 3).
Native American, African American, and Latino chil-
dren were less likely than Asian/Pacific Islander and
white children to have all of their medical care needs
TABLE 3 Access to Medical and Dental Care for US Children 0 to 17 Years Old (N ⴝ 102 353) According to Race/Ethnicity
Access Measure Mean or Proportion for Each Racial or Ethnic Group P
White Latino African
American
Asian/Pacific
Islander
Native
American
Multiracial
Insurance coverage at time of survey, % ⬍.0001
None 5.7 20.6 7.2 3.4 15.5 7.1
Public 17.5 43.9 49.1 16.2 49.7 29.2
Private 76.2 34.1 42.8 78.6 30.7 62.8
Insured, type unknown 0.7 1.4 1.0 1.9 4.1 1.0
Sporadically insured in past year, % 8.7 17.4 13.4 7.8 19.4 12.3 ⬍.0001
Has dental insurance, % 78.3 67.6 83.6 85.3 66.2 81.8 ⬍.0001
Has usual source of medical care, % 89.5 68.3 77.3 86.6 60.9 85.4 ⬍.0001
Received all needed medical care, %
a
99.3 98.6 98.5 99.99 96.5 97.8 ⬍.0001
Reason for unmet medical care need, %
b
Transportation barrier 3.9 3.9 6.6 0 45.1 1.2 .0001
No insurance 37.4 55.4 49.3 100 15.4 13.1 .003
No one accepts child’s insurance 3.3 1.7 3.2 0 3.1 14.9 .01
Treatment is ongoing 1.7 3.6 1.2 0 20.1 4.1 .02
Doctor didn’t know how to provide care 5.1 2.1 0.4 0 9.1 10.5 .03
Health plan problem 14.3 7.9 19.8 0 17.4 41.1 ⬍.05
Any problem getting specialty care 20.6 32.7 23.4 46.0 31.8 24.8 ⬍.0001
Needed but did not get all needed prescription
medications in past 12 mo, %
1.9 3.4 4.5 1.3 3.2 2.1 ⬍.0001
Received all needed dental care, %
c
97.8 94.7 95.2 96.1 93.0 95.2 .0001
Reason for unmet dental care need, %
b
Dentist did not know how to provide care 0.9 1.6 4.0 26.5 11.0 1.0 .0001
No insurance 32.1 35.6 26.0 5.2 4.1 23.9 .002
Did not know where to go for treatment 4.3 5.7 2.0 26.5 1.8 3.7 .02
Health plan problem 8.7 16.5 7.2 32.0 1.1 8.8 .02
a
Data are only if made a physician visit in past 12 months.
b
Data are only access barriers with significant racial or ethnic disparities; see text for other barriers.
c
Data are only if patient made a dental visit in past 12 months.
Data source: the NSCH.
e290 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
met (Table 3). Transportation barriers are significantly
more often responsible for unmet medical care needs
among Native American children, at 45%. Lack of in-
surance was a reason for unmet medical need for ap-
proximately half of Latino and African American chil-
dren and 100% of Asian/Pacific Islander children. Lack
of acceptance of the child’s insurance was a frequent
reason for the unmet medical care need for multiracial
children (15%), whereas the ongoing nature of the
treatment was cited by 20% of Native Americans. Ap-
proximately 10% of both multiracial and Native Amer-
ican parents cited the doctor not knowing how to pro-
vide care as a reason for unmet need, whereas health
plan problems were cited by ⬎40% of parents of multi-
racial children and 14% to 20% of African American,
Native American, and white children.
Asian/Pacific Islander children were most likely to en-
counter any problem getting specialty care, at ⬃50%. Ap-
proximately one third of Latino and Native American chil-
dren also encountered problems getting specialty care
compared with approximately one fourth of multiracial,
23% of African American, and 20% of white children
(Table 3). African American children (5%) were slightly
more likely to have not obtained all of their needed pre-
scription medications in the past year, whereas Asian/
Pacific Islander children (1%) were least likely to have
unmet prescription needs.
Nonwhite racial/ethnic groups of children had greater
unmet dental care needs than white children, with Na-
tive Americans (7%) at particularly high risk (Table 3).
More than one fourth of Asian/Pacific Islander children’s
parents attributed their unmet dental care need to their
dentist not knowing how to provide care; Native Amer-
ican parents (11%) also frequently cited this reason.
Lack of dental insurance coverage was cited as a reason
for unmet pediatric dental needs by all of the groups
except for Asians/Pacific Islanders and Native Ameri-
cans. Asian/Pacific Islander children had unmet dental
needs substantially more often because of parents not
knowing where to go for treatment, at 27%. Dental
health plan problems were a reason for unmet dental
needs most often for Asian/Pacific Islander (32%) and
Latino (17%) children.
Use of Medical and Dental Care and Prescription Medications
Almost one third of Native American, Asian/Pacific Is-
lander, and Latino children had made no physician visit
in the past year compared with only ⬃20% to 21% for
other racial/ethnic groups (Table 4). Somewhat greater
proportions of Native American (5%) and African Amer-
ican (4%) children made ⱖ3 ED visits in the past year
compared with other racial/ethnic groups (2%–3%).
Mental health care in the past year was most often
received by multiracial children and least often by Asian/
Pacific Islander children.
Latino (18%) and multiracial (16%) children had the
highest risk of never having seen a dentist. Among chil-
dren who had seen a dentist, Native Americans (15%)
were most likely to have made no preventive dental visit
in the past year; a high proportion of Latinos (12%) and
African Americans (11%) also made no preventive den-
tal visit in the past year, compared with only 5% to 7%
among the other racial/ethnic groups.
Prescription medication use and need was most com-
mon among multiracial (25%), African American
(22%), and white (22%) children compared with other
racial/ethnic groups (14%–17%; Table 4). For most
racial/ethnic groups, approximately half of the children
used a prescription medication in the past year in con-
trast to only approximately one third of Asian/Pacific
Islander and African American children. A slightly
higher risk of not using but needing a prescription med-
TABLE 4 Use of Medical Care, Dental Care, and Prescription Medications Among US Children 0 to 17 Years Old (N ⴝ 102 353) According to
Race/Ethnicity
Use of Service Measure Mean or Proportion for Each Racial or Ethnic Group P
White Latino African
American
Asian/Pacific
Islander
Native
American
Multiracial
No physician visit in last 12 mo, % 20.7 27.9 19.5 29.2 29.5 20.3 ⬍.0001
No. of ED visits in last year, % ⬍.0001
0 82.2 82.0 77.3 85.0 73.5 78.3
1–2 15.8 15.4 18.8 13.4 21.6 19.0
ⱖ3 2.0 2.6 3.9 1.6 4.9 2.8
Received mental health care in past
12 mo, %
a
7.6 5.3 5.9 1.3 6.3 9.2 ⬍.0001
Never seen dentist, % 13.1 17.8 12.3 11.8 14.4 16.0 ⬍.0001
No routine preventive dental visit in
last 12 mo, %
ab
4.8 11.8 11.3 6.8 15.0 6.7 ⬍.0001
Needs/uses prescription medication, % 21.8 14.3 22.3 16.3 16.9 25.0 ⬍.0001
Used prescription medication in past
12 mo, %
⬍.0001
Yes 53.0 44.8 37.7 35.5 43.5 46.7
No, did not need 45.1 51.7 57.8 63.2 53.3 51.2
No, but needed 1.9 3.4 4.5 1.3 3.2 2.1
a
Data are only for children ⬎12 months old.
b
Data are only among those who have ever made a dental visit.
Data source: the NSCH.
PEDIATRICS Volume 121, Number 2, February 2008 e291
by on May 17, 2008 www.pediatrics.orgDownloaded from
ication in the past 12 months was seen for African Amer-
ican, Latino, and Native American children.
Multivariable Analyses
Medical and Oral Health Status
Compared with white children, Latino, African Ameri-
can, and multiracial children had significantly greater
adjusted odds of their health status and teeth condition
both not being excellent or very good (Table 5). Native
American and African American children had double the
odds and Latino children 1.4 times the odds of white
children of being OARO. African American and Asian/
Pacific Islander children were less likely than whites to
need more medical care than others, whereas multiracial
and African American children were more likely than
white children to have limited abilities and difficulty
with emotions, concentration, behavior, or interper-
sonal relations. Native Americans had double the odds of
white children of needing or getting special therapy,
whereas Asian/Pacific Islander children were one third
less likely. Compared with whites, African Americans
and Asian/Pacific Islanders had lower odds of emotional,
developmental, or behavioral problems needing treat-
ment or counseling, and Asian/Pacific Islander children
had lower odds of a learning disability.
African American, multiracial, and Latino children had
significantly greater odds of having asthma than white
children (Table 5). Native Americans had almost double
the odds of whites of having hearing or vision problems,
whereas African Americans had a lower likelihood. Com-
pared with white children, Asian/Pacific Islander, African
American, and Latino children had lower odds of ADHD,
and Asian/Pacific Islander and African American children
had lower odds of depression or anxiety. African Ameri-
cans had a greater odds and Asian/Pacific Islanders and
Native Americans lower odds of behavior problems versus
whites. Lower odds of bone, joint, or muscle problems
occurred in Asians/Pacific Islanders, and lower odds of
developmental delay occurred in Asians/Pacific Islanders
and African Americans. African American children had a
significantly lower odds of diabetes mellitus, whereas Na-
tive Americans had a nonsignificant trend of almost triple
the odds of diabetes mellitus compared with whites. Diges-
tive allergies were significantly more likely in multiracial
versus white children, and skin allergies occurred more
frequently in African Americans and multiracial children.
There were greater odds of speech problems in African
American versus white children but lower odds of frequent
ear infections for both African Americans and Latinos.
Access to Medical and Dental Care
Compared with white children, Native American chil-
dren had 2.4 times the odds, Latin children had 1.5 times
the odds, and multiracial children had 1.3 times the odds
TABLE 5 Multivariable Analyses of Racial/Ethnic Disparities in Medical and Oral Health Status Among US Children 0 to 17 Years Old
(N ⴝ 102 353)
Measure Odds Ratio (95% Confidence Interval) vs White Children
Latino African
American
Asian/Pacific
Islander
Native
American
Multiracial
Health not excellent or very good 1.84 (1.62–2.10) 1.93 (1.74–2.14) NS NS 1.32 (1.10–2.10)
Teeth condition not excellent or very good 1.65 (1.48–1.83) 1.65 (1.52–1.79) NS NS 1.39 (1.20–1.61)
OARO 1.38 (1.24–1.54) 1.86 (1.71–2.02) NS 2.25 (1.75–2.89) NS
Needs more medical care than others NS 0.81 (0.72–0.91) 0.45 (0.22–0.92) NS NS
Has limited abilities NS 1.29 (1.13–1.48) NS NS 1.34 (1.03–1.74)
Needs or gets special therapy
a
NS NS 0.35 (0.15–0.82) 1.67 (1.15–2.44) NS
Difficulty with emotions, concentration, behavior,
or interpersonal relations
NS 1.27 (1.15–1.40) NS NS 1.45 (1.22–1.71)
Emotional, developmental, or behavioral problems
needing treatment or counseling
NS 0.850 (0.730–0.999) 0.25 (0.11–0.55) NS NS
Learning disability NS NS 0.24 (0.12–0.47) NS NS
Asthmatic 1.34 (1.16–1.54) 1.61 (1.45–1.78) NS NS 1.38 (1.17–1.62)
Hearing or vision problems NS 0.55 (0.42–0.71) NS 1.70 (1.06–2.74) NS
ADHD 0.73 (0.58–0.91) 0.71 (0.61–0.83) 0.36 (0.12–1.09) NS NS
Depression or anxiety NS 0.49 (0.39–0.61) 0.20 (0.05–0.70) NS NS
Behavior problems NS 1.20 (1.01–1.42) 0.18 (0.06–0.50) 0.64 (0.41–0.99) NS
Bone, joint, or muscle problems NS NS 0.28 (0.12–0.64) NS NS
Diabetes NS 0.55 (0.33–0.91) NS 2.61 (0.86–7.88)
b
NS
Developmental delay NS 0.67 (0.55–0.83) 0.22 (0.10–0.46) NS NS
Digestive allergies NS NS NS NS 1.57 (1.20–2.06)
Skin allergies NS 1.82 (1.64–2.02) NS NS 1.59 (1.34–1.90)
Speech problems NS 1.34 (1.09–1.64) NS NS NS
ⱖ3 ear infections in last 12 mo 0.74 (0.57–0.95) 0.67 (0.55–0.82) NS NS NS
Multivariate analyses were adjusted for primary language spoken at home, child’s age and insurance coverage, caregiver’s educational attainment and employment status, number of children in
the household, number of adults in the household, and poverty level. NS indicates not significant.
a
Physical, occupational, or speech therapy.
b
Nonsignificant trend, with P ⫽ .09.
Data source: the NSCH.
e292 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
of being uninsured, whereas Asian/Pacific Islander chil-
dren were less likely to be uninsured (Table 6). All of the
nonwhite racial/ethnic groups, except for Asians/Pacific
Islanders, also were more likely to have had sporadic
insurance coverage in the past year. Native Americans
had almost double the odds of whites of lacking dental
insurance, whereas Asians/Pacific Islanders, African
Americans, and multiracial children were less likely to
lack dental insurance.
Compared with white children, Native Americans
had 4 times the odds, African Americans and Latinos
approximately double the odds, and multiracial children
1.4 times the odds of having no usual source of medical
care (Table 6). Native Americans and multiracial chil-
dren had approximately triple the odds of whites of not
receiving all of their needed medical care, whereas
Asians/Pacific Islanders had substantially lower odds of
unmet medical care need. Multiracial children had ⬃6
times the odds of unmet medical care need because of
health plan problems and no one accepting the child’s
insurance. For other barriers resulting in unmet medical
needs, Latino parents were less likely to cite no one
accepting the child’s insurance, multiracial children’s
parents were less likely to cite no insurance, and African
American parents were less likely to cite cost. Native
Americans had a 20 times greater odds of transportation
problems as the cause of unmet medical needs, and
parents of Latino and Native American children were
more likely to report ongoing treatment as a reason for
unmet medical needs.
Both Asian/Pacific Islander and Latino children were
significantly more likely than white children to have a
problem getting specialty care (Table 6). Both African
American and Latino children had approximately double
the odds of whites of needing but not getting all of their
needed prescription medications in the past year.
Multiracial, Native American, and African American
children had double the odds of white children of not
receiving all of their needed dental care (Table 6). Trans-
portation problems were substantially more likely to be
the reason for unmet dental care needs among Asians/
Pacific Islanders and Native Americans. Asians/Pacific
Islanders had 15 times the odds, Native Americans had
10 times the odds, and African Americans had ⬃5 times
the odds of whites of unmet dental needs because of
parental reports that the dentist did not know how to
TABLE 6 Multivariable Analyses of Racial/Ethnic Disparities in Access to Medical and Dental Care Among US Children 0 to 17 Years Old
(N ⴝ 102 353)
Measure Odds Ratio (95% Confidence Interval) vs White Children
Latino African
American
Asian/Pacific
Islander
Native American Multiracial
No health insurance
a
1.46 (1.25–1.70) NS 0.38 (0.18–0.80) 2.41 (1.75–3.32) 1.31 (1.01–1.69)
Sporadically insured in past year
a
1.35 (1.17–1.57) 1.41 (1.26–1.60) NS 2.15 (1.62–2.85) 1.42 (1.18–1.70)
No dental insurance
a
NS 0.67 (0.61–0.74) 0.42 (0.26–0.67) 1.62 (1.28–2.05) 0.78 (0.66–0.93)
No usual source of medical care 1.77 (1.56–2.00) 1.99 (1.81–2.20) NS 3.96 (3.05–5.14) 1.37 (1.14–1.65)
Did not receive all needed medical care
b
NS NS 0.030 (0.004–0.200) 2.99 (1.11–8.03) 2.83 (1.78–4.51)
Reason for unmet medical care need
Health plan problem NS NS NE NS 5.91 (2.39–14.6)
No one accepts child’s insurance 0.27 (0.10–0.76) NS NE NS 6.26 (1.77–22.2)
No insurance NS NS NE NS 0.21 (0.08–0.51)
Cost NS 0.36 (0.16–0.82) NS NS NS
Transportation NS NS NE 20.40 (2.51–165.50) NS
Treatment is ongoing 6.08 (1.36–27.1) NS NE 20.70 (2.44–174.60) NS
Any problem getting specialty care 1.36 (1.07–1.72) NS 2.98 (1.35–6.56) NS NS
Needed but did not get all needed prescription
medications in past 12 mo
1.66 (1.25–2.22) 1.96 (1.51–1.55) NS NS NS
Did not receive all needed dental care
c
NS 2.10 (1.63–2.70) NS 2.21 (1.09–4.45) 2.42 (1.56–3.75)
Reason for unmet dental care need
c
Transportation NS NS 16.70 (1.82–152.60) 5.10 (1.55–16.7) NS
Dentist did not know how to provide care NS 4.51 (1.67–12.2) 14.90 (2.44–90.80) 10.3 (1.40–94.0) NS
No one accepts child’s insurance NS NS 11.00 (1.63–74.10) NS NS
Inconvenient times or could not get an
appointment
NS NS NS 5.43 (2.05–14.40) NS
No dental insurance NS NS 0.06 (0.01–0.42) 0.06 (0.02–0.19) NS
Cost NS 0.60 (0.41–0.90) NS 0.12 (0.04–0.35) NS
Treatment is ongoing NS NS NE 5.33 (1.46–19.50) NS
Multivariate analyses were, except as noted below, adjusted for primary language spoken at home, child’s age and health insurance coverage, caregiver’s educational attainment and employment
status, number of children in the household, number of adults in the household, and poverty level. NS indicates not statistically significant; NE, not estimable, because of small sample size.
a
Adjusted for primary language spoken at home, child’s age, caregiver’s educational attainment and employment status, number of children in the household, number of adults in the household,
and poverty level.
b
Only if child made a physician visit in past 12 months.
c
Only for those making a dental visit in past 12 months; adjusted for primary language spoken at home, child’s age and dental insurance coverage, caregiver’s educational attainment and
employment status, number of children in the household, number of adults in the household, and poverty level.
Data source: the NSCH.
PEDIATRICS Volume 121, Number 2, February 2008 e293
by on May 17, 2008 www.pediatrics.orgDownloaded from
provide care. Unmet dental needs were significantly
more likely because of no one accepting the child’s den-
tal insurance among Asians/Pacific Islanders and incon-
venient appointment times or inability to get an appoint-
ment among Native Americans. Unmet dental needs
because of no dental insurance were less likely in
Asians/Pacific Islanders and Native Americans and be-
cause of cost were less likely for Native Americans and
African Americans. Native Americans were more likely
than whites to cite ongoing treatment as a reason for
unmet dental needs.
Use of Medical Care, Dental Care, and Prescription
Medications
All 5 of the nonwhite racial/ethnic groups of children
were significantly more likely than white children to
have made no physician visit in the past year (Table 7).
Both Native Americans and African Americans were
more likely to have made ⱖ1 ED visit in the past year.
Asian/Pacific Islander and African American children
had greater odds of white children of having received no
mental health care in the past year.
African American, multiracial, and Native American
children had significantly greater odds than white chil-
dren of having had no preventive dental visit in the past
year (Table 7). Multiracial children were more likely and
Native Americans less likely than white children to need
or use a prescription medication, whereas all of the
nonwhite groups of children were significantly more
likely than white children to have not been given a
prescription medication in the past year.
DISCUSSION
Disparities for Nonwhite Racial/Ethnic Groups
The study findings document that racial/ethnic minority
children in the United States experience multiple dispari-
ties in medical and oral health, access to care, and use of
services. Compared with white children, all 5 of the mi-
nority groups were significantly less likely (after adjust-
ment) to have had a physician visit and to have been given
a prescription medication in the past year. Compared with
white children, at least 3 minority groups had significantly
greater adjusted odds of suboptimal health status and con-
dition of the teeth, being OARO, asthma, no health insur-
ance, sporadic health insurance in the past year, no usual
source of medical care, unmet dental care needs, and no
routine preventive dental visit in the past year.
These data indicate that minority children in America
often face a “triple threat” of greater risks of suboptimal
medical and oral health status, impaired access to medical
and dental care, and lower receipt of prescription medica-
tions and essential medical and dental services. The reduc-
tion and elimination of such disparities, therefore, may
require innovative, comprehensive approaches and con-
ceptual frameworks, including considering the family and
community milieu of the child,
6
carefully disaggregating
socioeconomic status and race/ethnicity,
7
consideration of
disparities as a quality issue,
8
and understanding the inter-
play of both underlying risk status and differential access to
effective interventions.
9
Disparities for Latino Children
Certain disparities are particularly marked for specific
minority groups, and appreciation of these noteworthy
disparities may be useful for clinicians, health systems,
and policy makers addressing the needs of diverse pop-
ulations. More than one third of Latino children had
suboptimal (not excellent or very good) health status,
and more than one half had suboptimal condition of the
teeth, the highest proportions of any group, and Latino
children had approximately double the adjusted odds of
white children of suboptimal health status and teeth
condition. As has been documented in several other
studies over 3 decades,
10–14
Latino children had the high-
est prevalence of being uninsured, at 21%, and double
the adjusted odds of uninsurance compared with white
children. Approximately one third of Latino children
had no usual source of medical care and one-third en-
countered a problem getting specialty care, and Latino
children had significantly greater adjusted odds than
white children of no usual source of medical care, not
getting all of their needed prescription medications, and
having problems getting specialty care.
Disparities for African American Children
African American children experienced the greatest
number of disparities of any racial or ethnic group in
TABLE 7 Multivariable Analyses of Racial/Ethnic Disparities in Use of Medical Care, Dental Care, and Prescription Medications Among US
Children 0 to 17 Years Old (N ⴝ 102 353)
Measure Odds Ratio (95% Confidence Interval) vs White Children
Latino African
American
Asian/Pacific
Islander
Native
American
Multiracial
No physician visit in past 12 mo 1.18 (1.02–1.36) 1.30 (1.17–1.45) 2.62 (1.76–3.90) 1.59 (1.21–2.08) 1.26 (1.02–1.55)
One more ED visits in past 12 mo NS 1.19 (1.09–1.30) NS 1.57 (1.21–2.02) NS
Received no mental health care in past 12 mo NS 1.74 (1.47–2.06) 5.11 (2.31–11.3) NS NS
No routine preventive dental visit in past 12 mo NS 1.43 (1.28–1.60) NS 1.36 (1.00–1.85) 1.41 (1.19–1.68)
Needs or uses prescription medication NS NS NS 0.76 (0.57–1.01) 1.20 (1.03–1.38)
Not given prescription medication in past 12 mo 1.31 (1.18–1.46) 1.79 (1.64–1.95) 2.32 (1.65–3.25) 1.33 (1.04–1.71) 1.37 (1.19–1.57)
Multivariate analyses wereadjusted for primary language spoken at home, child’s age and health insurance coverage (or dental insurance coverage, in the case of preventive dental visits), caregiver’s
educational attainment and employment status, number of children in the household, number of adults in the household, and poverty level. NS indicates not statistically significant; NE, not
estimable, because of small sample size.
Data source: the NSCH.
e294 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
medical and oral health status, with significantly greater
adjusted odds than white children for 8 measures. Afri-
can American children had approximately double the
odds of white children of suboptimal health status and
teeth condition. More than half of African American
children were OARO, and they had approximately dou-
ble the adjusted odds of whites of OARO. African Amer-
ican children had the highest prevalence of limited abil-
ities (9%) and difficulty with emotions, concentration,
behavior, or interpersonal relations (25%), disparities
that persist after adjustment. Consistent with other re-
cent national data,
15
African American children had the
highest asthma prevalence of any racial or ethnic group,
although the magnitude (18%) in this study exceeded
that of previous work; after adjustment, African Amer-
icans still had double the odds of asthma versus whites.
African American children also had a particular high
prevalence and greater adjusted odds of skin allergies
and speech problems. For access to medical and dental
care, African American children had significantly greater
adjusted odds than white children of sporadic insurance,
no usual source of medical care, unmet prescription
medication need, unmet dental need, and dentists not
knowing how to provide care as the reason for unmet
dental need. Similar to previous research, African Amer-
icans were found to have greater odds of ⱖ1 ED visit, no
routine preventive dental visit, and not receiving a pre-
scription medication in the past year.
14,16,17
Disparities for Asian/Pacific Islander Children
Asian/Pacific Islander children experienced significantly
better medical and oral health status than white children
for 8 indicators, including substantially lower adjusted
risks of limited abilities; needing or getting special ther-
apy; emotional, developmental, or behavioral problems
needing treatment or counseling; learning disabilities;
ADHD; depression or anxiety; behavior problems; bone,
joint, or muscle problems; and developmental delay. The
magnitude of these lower risks ranged from 2 to as much
as 5 times lower odds compared with white children.
This is the first report (to our knowledge) to support
such consistently and substantially lower risks for Asian/
Pacific Islander children. The data do not permit deter-
mination of whether these findings might at least in part
reflect reduced access to care, resulting in a lower like-
lihood of physician-diagnosed conditions, functional
limitations, and treatment. Of note, Asian/Pacific Is-
lander children had significantly lower adjusted risks
than white children of lacking medical or dental insur-
ance and having unmet medical care needs.
In contrast, among those needing specialty care, ap-
proximately half of Asians/Pacific Islanders experienced
problems getting specialty care (the highest prevalence
for any group), and they had the highest adjusted risk of
problems getting specialty care, at triple the odds of
white children. Asian/Pacific Islander children also ex-
perienced substantially higher adjusted odds of unmet
dental care need because of transportation problems, the
dentist not knowing how to provide care, and no one
accepting the child’s insurance, with odds that range
from 11 to 17 times greater than for white children. In
addition, Asian/Pacific Islander children had the highest
adjusted odds of having made no physician visit, receiv-
ing no mental health care, and receiving no prescription
medication in the past year.
Consistent with these findings, previous work re-
ported Asian/Pacific Islander children’s disparities for
no contact with a physician in the past year and no
medication receipt in the past 3 months (for certain
subgroups).
18
However, this is the first published study
(to our knowledge) to report that Asian/Pacific Islander
children experience a unique constellation of better
medical and oral health, better health and dental insur-
ance coverage, and fewer unmet medical needs but sub-
stantially higher odds of problems obtaining specialty
care, selected barriers causing unmet dental needs, fewer
physician visits, no mental health care, and lower receipt
of prescription medications in the past year.
Disparities for Native American Children
Native American children were at particularly high risk
for OARO, with the highest prevalence (55%) and great-
est adjusted odds (more than double) versus white chil-
dren. The prevalence of diabetes mellitus among Native
American children (1%) was the highest for any racial or
ethnic group, exceeding the prevalence of this disease in
other racial/ethnic groups of children by 2 to 10 times.
One in 9 Native American children needed or got special
therapy, by far the highest prevalence, and Native Amer-
icans had approximately twice the adjusted odds of
whites of needing or getting special therapy. Native
American children also had an especially high preva-
lence of hearing or vision problems, which, at 6%, is
double to triple the prevalence among other racial or
ethnic groups, and Native Americans had approximately
double the adjusted odds of whites of having hearing or
vision problems.
Native American children had the worst access to
medical and dental care, both in terms of the sheer
number of disparities (a total of 6) and the magnitude.
Native Americans had the highest adjusted odds of any
racial or ethnic group of children of lacking health and
dental insurance and being sporadically insured, at ap-
proximately double the odds of white children for all 3 of
the outcomes. Native Americans had substantially
greater adjusted odds than whites of no usual source of
medical care, at quadruple the odds, of unmet medical
care needs, at triple the odds, and of unmet dental care,
at double the odds. Transportation problems were a
substantial reason for unmet medical and dental needs,
and other important reasons for unmet dental needs
included the dentist not knowing how to provide care
and inconvenient appointment times or not being able
to get appointments.
Native American children had the highest adjusted
odds of ⱖ1 ED visit in the past year, at double the odds
of white children. Previous research on ED use in chil-
dren could not report ED use rates for Native American
children because of small sample sizes,
14,19,20
so the cur-
rent study findings fill an important gap and document a
previously unreported (to our knowledge) risk for Na-
tive Americans. Compared with white children, risks of
PEDIATRICS Volume 121, Number 2, February 2008 e295
by on May 17, 2008 www.pediatrics.orgDownloaded from
no physician visit and no routine preventive dental visit
in the past year were significantly higher for Native
Americans. The study findings complement previous re-
search documenting poor condition of the teeth in Na-
tive American children
21
and disparities in leading health
indicators among Native American adolescents.
22
Disparities for Multiracial Children
Very little has been published on disparities for multira-
cial children,
16
most likely because of insufficient sample
sizes for this group in most national databases. Multira-
cial children experienced multiple disparities in medical
and oral health status. They had significantly higher
adjusted odds than white children of suboptimal health
status and teeth condition and the highest odds of lim-
ited abilities, digestive allergies, and difficulties with
emotions, concentration, behavior, or interpersonal re-
lations. Multiracial children had 1.4 times the adjusted
odds of asthma versus white children, and the preva-
lence of asthma among multiracial children, at 15%, was
second only to African Americans. Multiracial children
had significantly greater adjusted odds of digestive dis-
eases than any other group, and they had significantly
higher odds of asthma and skin allergies, at levels ex-
ceeded only by African American children.
Multiracial children had significantly higher adjusted
odds versus white children of being uninsured and spo-
radically insured and had the highest odds of unmet
dental care needs. They also had approximately triple
the adjusted odds of whites of unmet medical needs and
6 times the odds of health plan problems and no one
accepting the child’s insurance as the reasons for unmet
medical needs, distinguishing multiracial children as the
only minority group experiencing higher risks for these
reasons. Multiracial children also had the highest risk of
unmet dental care needs, at more than double the ad-
justed odds of whites. The also had significantly greater
odds than whites of no routine preventive dental visit in
the past 12 months, need or use of prescription medica-
tion, and not being given a prescription medication in
the past 12 months.
This is the first study (to our knowledge) to report
health and health care disparities for multiracial children
using nationwide data. A recent study of children with
special health care needs
23
found high unmet need for
vision care among multiracial children, consistent with
our findings of high unmet medical and dental care
needs for the general population of multiracial children.
Disparities in Overweight
Consistent with recent national data,
24,25
the study find-
ings document a high prevalence of OARO among US
children, ranging from more than one third to more
than one half of children, depending on the racial or
ethnic group. Previous analyses, however, did not have
adequate sample sizes to assess overweight and OARO
among Asian/Pacific Islander, Native American, and
multiracial children or among Latino children as a whole
(ie, other than Mexican American children), so the cur-
rent study eliminates key knowledge gaps. The study
findings reveal that Native American children have the
highest prevalence of OARO, at 55%. Although nation-
ally representative data on overweight among Native
American children have not been available previously,
these findings are consistent with high levels of OARO
reported for individual tribes, Native American popula-
tions in specific regions, and multiple tribes across the
country.
26–30
NSCH data also revealed a high prevalence
of OARO among Asian/Pacific Islander children, at 35%,
equivalent to the prevalence in white children. These
are the first published national rates (to our knowledge)
for Asian/Pacific Islander children; the only comparable
data come from a study of young children in Hawaii,
which found no difference in overweight risk in Asian
versus white children, but significantly higher adjusted
odds of overweight for Samoan children.
31
Multiracial
children were also found to have a high prevalence of
OARO, at 40%; no other published studies have exam-
ined OARO among multiracial children. Caution should
be exercised in interpreting NSCH BMI data, however,
because these data are based on parentally reported
height and weight, rather than actual measurements.
Consistent with previous work,
24,25
high OARO prev-
alence rates were found for African American (52%),
Latino (47%), and white (35%) children. These NSCH
rates are higher than those reported in analyses of the
1999 –2002 National Health and Nutrition Examination
Survey (NHANES) for African American (35%), Mexi-
can American (40%), and white (28%) children, which
may be because of several factors: (1) weight and height
in the NSCH were derived from parental reports,
whereas weight and height were directly measured in
NHANES subjects; (2) the NSCH analyses were based on
children 0 to 17 years old, whereas NHANES analyses
examined children 6 to 19 years old; and (3) the NSCH
data (2003–2004) are somewhat more recent than the
NHANES data (1999 –2002).
Importance of Inclusion of All of the Major Racial/Ethnic
Groups and Multiracial Children
The study findings document the importance of includ-
ing all of the major racial/ethnic groups and multiracial
children in analyses of racial/ethnic disparities in the
health and health care of children. Many studies of
racial/ethnic disparities are limited to comparisons of
whites, African Americans, and Latinos or even just
whites and African Americans. In this study, omission of
Native American, Asian/Pacific Islander, and multiracial
children would have resulted in many unique disparities
being missed and several of the highest prevalence rates
being ignored for multiple health, dental, access, and
use-of-services outcomes. These results suggest that spe-
cial efforts should be made to collect and analyze data for
all of the racial/ethnic groups and multiracial children,
particularly when a comprehensive, accurate assessment
of disparities is required.
Study Limitations
Certain study limitations should be noted. The NSCH did
not collect data on racial/ethnic subgroups or tribal groups,
e296 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
subcategories known to be important in identifying health
care disparities,
5,18,32,33
so important subgroup differences
and the heterogeneity of individual racial/ethnic groups
could not be examined in additional detail. The children’s
conditions were identified by parental report, not direct
physician diagnosis, so the prevalence of conditions could
be overestimated or underestimated, and there could have
been racial/ethnic variation in parental perception and as-
sessment. NSCH data were collected only on the primary
language spoken at home and not parental limited English
proficiency, although the latter language measure has been
shown to be more useful when examining health status,
access to care, and use of services.
34
NSCH interviews were
conducted only in English and Spanish
3
; it is unclear how
many households had to be excluded because the parent or
guardian did not have adequate proficiency in English or
Spanish. NSCH data also were not available on the immi-
gration status of children or parents.
Study Strengths
A main strength of this study was that analyses were
performed for all 5 of the major US racial/ethnic groups.
In addition, disparities also could be examined for mul-
tiracial children. Additional strengths included the large,
nationally representative sample of ⬎102 000 children
and the comprehensive set of outcomes in the NSCH
that encompassed medical and oral health, access to
care, and use of services.
Practice and Policy Implications
The study findings suggest several important action steps
that may prove useful in the reduction and elimination
of racial/ethnic disparities in children. Previously unre-
ported and substantial disparities in Native American,
Asian/Pacific Islander, and multiracial children indicate
the need for more comprehensive data collection, anal-
yses, and monitoring on disparities in all of the major
racial/ethnic groups and multiracial children. Stark dis-
parities in nonfinancial barriers to care, sporadic insur-
ance, and lack of health insurance suggest an urgent
need for improvements in access to care and reductions
in unmet needs. The pronounced disparities for specific
racial/ethnic groups and multiracial children may serve
as a useful guide for clinicians and public health provid-
ers for tailoring preventive and routine care, treatment,
and programs aimed at reducing disparities. Targeted
community-based interventions may prove especially
effective in eliminating racial/ethnic disparities, as has
been documented in a recent randomized, controlled
trial.
35
Federal legislation aimed at reducing racial/ethnic
disparities in health and health care, such as the Minor-
ity Health Improvement and Health Disparity Elimina-
tion Act
36
and the Community Health Workers Act of
2007,
37
could potentially have a major impact on the
reduction and elimination of disparities.
CONCLUSIONS
Racial/ethnic minority children in the United States ex-
perience 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
awareness of these noteworthy disparities may be useful
for clinicians, health systems, and policy makers in op-
timally addressing the needs of diverse populations.
Multiracial children also experience many disparities,
including the highest odds of limited abilities, digestive
allergies, unmet dental care needs, and difficulties with
emotions, concentration, behavior, or interpersonal re-
lations. Reduction and elimination of racial/ethnic dis-
parities in children may require more comprehensive
data collection, analyses, and monitoring of disparities in
all of the major racial/ethnic groups and multiracial chil-
dren, improvements in access to care and reducing un-
met needs, and targeted community-based interven-
tions.
REFERENCES
1. Agency for Healthcare Research and Quality. 2006 National
Healthcare Disparities Report. Rockville, MD: US Department of
Health and Human Services, Agency for Healthcare Research
and Quality; 2006: AHRQ Publication 07– 0012
2. Committee on Understanding and Eliminating Racial and Eth-
nic Disparities in Health Care. Literature review. In: Smedley
BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting
Racial and Ethnic Disparities in Health Care. Washington, DC:
National Academies Press; 2003:285–383
3. Blumberg SJ, Olson L, Frankel MR, Osborn L, Srinath KP,
Giambo P. Design and operation of the National Survey of
Children’s Health, 2003. Vital Health Stat. 2005;1(43):1–124
4. Stata Corp. Stata Survey Data Reference Manual: Release 8. College
Station, TX: Stata Corporation; 2003
5. Flores G, Bauchner H, Feinstein AR, Nguyen US. The impact of
ethnicity, family income, and parental education on children’s
health and use of health services. Am J Public Health. 1999;
89(7):1066 –1071
6. Mendoza FS, Fuentes-Afflick E. Latino children’s health and
the family-community health promotion model. West J Med.
1999;170(2):85–92
7. Weitzman M, Byrd RS, Auinger P. Black and white middle class
children who have private health insurance in the United
States. Pediatrics. 1999;104(1 pt 2):151–157
8. Beal AC. Policies to reduce racial and ethnic disparities in child
health and health care. Health Aff (Millwood). 2004;23:171–179
9. Wise PH. The anatomy of a disparity in infant mortality. Annu
Rev Public Health. 2004;24:341–362
10. Newacheck PW, McManus MA. Health insurance status of
adolescents in the United States. Pediatrics. 1989;84(4):
699 –708
11. Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF.
Access to medical care for children and adolescents in the
United States. Pediatrics. 1990;86(5):666 – 673
12. Newacheck PW, Hughes DC, Cisternas M. Children and health
insurance: an overview of recent trends. Health Aff (Millwood).
1995;14(1):244 –254
13. Passel JS. Demographic and social trends affecting the health of
children in the United States. Ambul Pediatr. 2002;2(2 suppl):
169 –179
14. Flores G, Olson L, Tomany-Korman SC. Racial and ethnic
disparities in early childhood health and healthcare. Pediatrics.
2005;115(2). Available at: www.pediatrics.org/cgi/content/
full/115/2/e183
15. Akinbami L; Centers for Disease Control and Prevention Na-
tional Center for Health Statistics. The state of childhood
asthma, United States, 1980 –2005. Adv Data. 2006;(381):1–24
16. Lewis C, Mouradian W, Slayton R, Williams A. Dental insur-
PEDIATRICS Volume 121, Number 2, February 2008 e297
by on May 17, 2008 www.pediatrics.orgDownloaded from
ance and its impact on preventive dental care visits for U.S.
children. J Am Dent Assoc. 2007;138(3):369 –380
17. Guevara JP, Mandell DS, Rostain AL, Zhao J, Hadley TR.
Disparities in reporting and treatment of health conditions in
children: an analysis of the Medical Expenditure Panel Survey.
Health Serv Res. 2006;41(2):532–549
18. Yu SM, Huang ZJ, Singh GK. Health status and health services
utilization among US Chinese, Asian Indian, Filipino, and
other Asian/Pacific Islander children. Pediatrics. 2004;113(1 pt
1):101–107
19. Burt CW, McCaig LF. Trends in hospital emergency depart-
ment utilization: United States, 1992–99. Vital Health Stat 13.
2001;(150):1–34
20. Elixhauser A, Machlin SR, Zodet MW, et al. Health care for
children and youth in the United States: 2001 annual report on
access, utilization, quality, and expenditures. Ambul Pediatr.
2002;2(6):419 – 437
21. Edelstein BL. Disparities in oral health and access to care:
findings of national surveys. Ambul Pediatr. 2002;2(2 suppl):
141–147
22. Harris KM, Gordon-Larsen P, Chantala K, Udry JR. Longitudi-
nal trends in race/ethnic disparities in leading health indicators
from adolescence to young adulthood. Arch Pediatr Adolesc Med.
2006;160(1):74 – 81
23. Heslin KC, Casey R, Shaheen MA, Cardenas F, Baker RS. Racial
and ethnic differences in unmet need for vision care among
children with special health care needs. Arch Opthalmol. 2006;
124(6):895–902
24. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and
trends in overweight among US children and Adolescents,
1999 –2000. JAMA. 2002;288(14):1728 –1732
25. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR,
Flegal KM. Prevalence of overweight and obesity among US
children, adolescents, and adults, 1999 –2002. JAMA. 2004;
291(23):2847–2850
26. Moore WE, Stephens A, Wilson T, Wilson W, Eichner JE. Body
mass index and blood pressure screening in a rural public
school system: the Healthy Kids Project. Prev Chronic Dis. 2006;
3(4):A114
27. Zephier E, Himes JH, Story M, Zhou X. Increasing prevalences
of overweight and obesity in Northern Plains American Indian
children. Arch Pediatr Adolesc Med. 2006;160(1):34 –39
28. Eisenmann JC, Katzmarzyk PT, Arnall DA, Interpreter C,
Malina RM. Growth and overweight of Navajo youth: secular
changes from 1955 to 1977. Int J Obes (Lond). 2000;24(2):
211–218
29. Neumark-Sztainer D, Story M, Resnick MD, Blum RW. Psy-
chosocial concerns and weight control behaviors among over-
weight and nonoverweight Native American adolescents. JAm
Diet Assoc. 1997;97(6):598 – 604
30. Jackson MY. Height, weight, and body mass index of American
Indian schoolchildren, 1990 –1991. J Am Diet Assoc. 1993;
93(10):1136 –1140
31. Baruffi G, Hardy CJ, Waslien CI, Uyehara SJ, Krupitsky D.
Ethnic differences in the prevalence of overweight among
young children in Hawaii. J Am Diet Assoc. 2004;104(11):
1701–1707
32. Williams DR, Jackson JS. Race/ethnicity and the 2000 Census:
recommendations for African American and other black pop-
ulations in the United States. Am J Public Health. 2000;90(11):
1728 –1730
33. Denny CH, Holtzman D, Cobb N. Surveillance for health be-
haviors of American Indians and Alaska Natives: findings from
the Behavioral Risk Factor Surveillance System, 1997–2000.
MMWR Surveill Summ. 2003;52(7):1–13
34. Flores G, Abreu M, Tomany-Korman SC. Limited English pro-
ficiency, primary language spoken at home, and disparities in
children’s health and healthcare: how language barriers are
measured matters. Public Health Rep. 2005;120(4):418 – 430
35. Flores G, Abreu M, Chaisson CE, et al. A randomized trial of
the effectiveness of community-based case management in
insuring uninsured Latino children. Pediatrics. 2005;116(6):
1433–1441
36. S. 4024 [109th]: Minority Health Improvement and Health
Disparity Elimination Act. Available at: www.govtrack.us/
congress/billtext.xpd?bill⫽s109-4024. Accessed March 12,
2007
37. S. 3975 [109th]: Community Health Workers Act of 2006. Avail-
able at: www.govtrack.us/congress/billtext.xpd?bill⫽h110-1968.
Accessed March 12, 2007
e298 FLORES, TOMANY-KORMAN
by on May 17, 2008 www.pediatrics.orgDownloaded from
DOI: 10.1542/peds.2007-1243
2008;121;e286-e298; originally published online Jan 14, 2008; Pediatrics
Glenn Flores and Sandra C. Tomany-Korman
Use of Services in US Children
Racial and Ethnic Disparities in Medical and Dental Health, Access to Care, and
& Services
Updated Information
http://www.pediatrics.org/cgi/content/full/121/2/e286
including high-resolution figures, can be found at:
References
http://www.pediatrics.org/cgi/content/full/121/2/e286#BIBL
at:
This article cites 29 articles, 15 of which you can access for free
Subspecialty Collections
http://www.pediatrics.org/cgi/collection/office_practice
Office Practice
following collection(s):
This article, along with others on similar topics, appears in the
Permissions & Licensing
http://www.pediatrics.org/misc/Permissions.shtml
tables) or in its entirety can be found online at:
Information about reproducing this article in parts (figures,
Reprints
http://www.pediatrics.org/misc/reprints.shtml
Information about ordering reprints can be found online:
by on May 17, 2008 www.pediatrics.orgDownloaded from
