Child health in the United States: Recent trends in racial/ethnic disparities
Highlights
► Racial/ethnic differences in child health in the United States across 17 indicators are examined. ► Little evidence that child racial/ethnic disparities in health are improving over time. ► For asthma, black–white disparities grew significantly larger between 1998 and 2009. ► Black children appeared more likely to be diagnosed with autism in the late 1990s compared to white children, but were less likely by 2009.
Introduction
Nowhere is the changing race and ethnic profile of the U.S. more evident than among children. While approximately 80% of U.S. adults over age 65 are non-Hispanic white, only 55% of individuals under age 18 fall into this category (U.S. Census Bureau 2010: Author calculations). These young cohorts of today indicate what the racial/ethnic demographic makeup of the U.S. adult population will be in the future. Some projections suggest that the U.S. will become a “majority minority” population by 2050 (i.e., non-Hispanic whites will comprise less than half of the U.S. population) (Ortman & Guarneri, 2009). These demographic trends have brought renewed policy and research attention to racial/ethnic minorities and their social and economic wellbeing, including understanding racial/ethnic differences in population health (Dentzer, 2011).
In the U.S., race is considered a key social determinant of health because of its long-standing association with poverty, discrimination, residential segregation, and unequal access to health care (Link & Phelan, 1995; Williams & Jackson, 2005). Numerous studies indicate that race/ethnicity is also an important social category that has strong associations with many health outcomes, even after adjusting for traditional measures of socioeconomic status (SES) such as education and income. These findings are believed to highlight differences in a complex set of social, economic, and biological assets available to different race/ethnic groups (Link & Phelan, 1995; Williams & Jackson, 2005; Williams, Mohammed, Leavell, & Collins, 2010) that are often unable to be fully accounted for or inadequately measured in empirical work (Krieger, Williams, & Moss, 1997; Krieger, Chen, Waterman, Rehkopf, & Subramanian, 2005; LaVeist, 2005). Indeed, from a social determinants of health perspective, race/ethnicity can be considered a “fundamental cause” of disease in the U.S. due to both historical (e.g., slavery and Jim Crow) and current (e.g., redlining and employment discrimination) forms of institutionalized discrimination. Race/ethnicity determines access to crucial resources, such as knowledge, money, prestige, power, as well as interpersonal resources, which assist people in avoiding diseases and their negative consequences.
Although accurate population-wide health data on racial/ethnic groups have only been available since the mid-20th century, racial/ethnic differences in health have become one of the most widely studied topics in U.S. health disparities research (Jones, LaVeist, & Lillie-Blanton, 1991; Williams, 1994). on differences between non-Hispanic blacks and whites, but there has been increasing attention given to Hispanics and Asian-origin populations, groups that have both grown rapidly as a result of changes in U.S. immigration policy in the mid-1960s.
An important policy concern is whether the U.S. is making progress toward reducing racial/ethnic inequalities in health (Agency for Healthcare Research and Quality, 2011; U.S. Department of Health and Human Services, 2010). However, with the exception of infant outcomes, the majority of the research examining U.S. racial/ethnic health differentials has focused on adults. Changes over time in race/ethnic differences among adults have been well characterized. For example, the black–white gap in life expectancy at age 50 has been relatively stable for males and declined steadily for females since the mid-1990s, although large disparities persist for both sexes. A number of recent studies have also examined trends in adult inequalities with respect to disability, major adult chronic diseases, and their risk factors (e.g., Burt et al., 1995; Crimmins & Saito, 2001; Egan, Zhao, & Axon, 2010; Lee, Brancati, & Yeh, 2011; Moss & Mannino, 2002; Williams & Collins, 1995).
Similarly, changes over time in infant mortality have also been well characterized, at least between blacks and whites. Throughout most of the twentieth century, the black–white ratio of the infant mortality rate (IMR) has increased (although the absolute black–white difference has declined over much of this period) (Singh & van Dyck, 2010). In 2000, the IMR among black infants was more than 2.5 times that of white infants, a relative disparity which decreased only slightly between 2000 and 2007 (Singh & van Dyck, 2010). In contrast, we know comparatively less about changes over time in race/ethnic inequalities in child health. With respect to race/ethnic differences, perhaps the best studied child health indicator is asthma (e.g., Akinbami, Moorman, Garbe, & Sondik, 2009; Akinbami & Schoendorf, 2002). One nationally representative study indicated that black–white differences in asthma prevalence increased between 1997 and 2003 (in that blacks were increasingly more likely to have asthma compared to whites) (McDaniel, Paxson, & Waldfogel, 2006). More recent changes in the black–white disparity have not been assessed to our knowledge. In addition, recent nationally representative evidence suggests that increases in the prevalence of autism have been more pronounced in whites compared to blacks and Hispanics between 1997 and 2008 (Boyle et al., 2011). A recent technical report by the American Academy of Pediatrics (AAP), which reviewed the existing evidence on race/ethnic disparities, concluded that “[r]acial/ethnic disparities in child health and health care are extensive, pervasive, and persistent, and occur across the spectrum of health and health care” (Flores & Committee On Pediatric Research, 2010; Flores & Tomany-Korman, 2008). The AAP report also indicated that few studies have examined trends in child health disparities.
Our objective is to examine whether racial/ethnic differences in child health have been widening or narrowing over time. We focus on the recent 1998–2009 period and compare trends occurring across multiple indicators of child health. This comparative perspective enables researchers to understand how the overall health of children is changing over time and whether there are variations in race/ethnic disparities across different dimensions of child health. In addition, this approach allows for the differentiation between improvements in child population health overall versus improvements in reducing racial/ethnic disparities in child health, both important but distinct national health policy goals (Koh, Graham, & Glied, 2011; National Research Council, 2004; U.S. Department of Health and Human Services, 2010). We utilize large-scale nationally representative data and include Asian-origin children, a group that has been traditionally excluded from the race/ethnic disparities literature.
Section snippets
Data and methods
We used the 1998–2009 waves of the National Health Interview Survey (NHIS), which is an annual and ongoing cross-sectional survey of the U.S. non-institutionalized population. We did not include earlier data because information on many child health indicators was not available or not comparable with data from more recent survey waves. Since 1998, the NHIS has consisted of a core component that collects a limited set of data from all members in a family including children and a “Sample Child”
Descriptive characteristics
Table 2 provides descriptive characteristics of all children in the core interview. Reflective of the demographic changes of U.S. children, nearly 40% of all children belonged to one of the minority race/ethnic groups. Hispanics represented the largest minority group (19%) followed by blacks (15%), Asians (4%), and Others (2%). The mean age of the sample was 8.20 years with some variation across race/ethnicity (Hispanic children were slightly younger at 7.55 years on average). White and Asian
Discussion
Our objective was to examine changes over time in race/ethnic disparities in child health. Unlike prior work, the strength of these analyses is the assessment of a comprehensive set of child health indicators and the implementation of a model-based approach to examine statistically significant changes in disparities over time. We examined both relative and absolute disparities. Our findings confirm prior reports of race/ethnic disparities across multiple child health indicators (Flores &
Acknowledgments
The authors would like to thank the Robert Wood Johnson Foundation Health and Society Scholars program for its financial support. Neil K. Mehta was additionally supported by the National Institute on Minority Health and Health Disparities' Loan Repayment Program. An earlier version of this paper was presented at the Population Association of America 2012 Annual Conference (San Francisco, CA). We thank Enrico A. Marcelli and three anonymous reviewers for their helpful comments. The content in
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