Studies have verified racial and ethnic disparities in health among low-income children. From birth until they reach adulthood, African American and Hispanic children fare far worse than white children on many sociodemographic and health system measures. One of the most important factors that interacts with racial and ethnic discrimination to impact health status is social stratification.
The Effect of Race, Ethnicity and Social Status on Child Health
Clinical evidence reveals a significant disparity between the health of children of color and that of children in the general population. Table 1 summarizes a representative sample of health discrepancies across a wide spectrum of diseases or illnesses.
Table 1. Health Discrepancies in Children of Color
An association was found between social inequality and cardiovascular risk in adolescence
Kendall & Hatton (2002)
Attention deficit hyperactivity disorder (ADHD)
Hispanic and African American children
There was a higher rate of ADHD in Ethnic minority children had poorer health and had less access to health care services
Chambers et al (2004)
Metabolic health risk
African Caribbean adolescent youth with internalized racism (INR).
A positive correlation was found between INR and metabolic health risk in African Caribbean adolescent youth
Nyborg et al (2003)
Simons et al (2002)
Psychological disorders
African American children
A correlation was found between racial discrimination and psychological symptoms in African American children
Whitbeck (2001)
Early substance abuse
American Indian children
A correlation was found between racial discrimination and drug abuse in American Indian children
Various hypotheses have been advanced to explain the various discrepancies. Dr. Lamberty from Brown University (Agency for Healthcare Research and Quality, 2000) evaluated a number of hypotheses that have been advanced to explain the impact of racial, ethnic, and socio-economic factors on the morbidity and mortality rates of children in the U.S. and found that most of these hypotheses named biological or socio-economic factors or a combination of the two. One widely tested hypothesis regards the impact of social stratification on the delivery of healthcare to socially disadvantaged children and the consequent impairment of the health of minority children. A strong association has been found between health disparities and social stratification in the U.S. The stratification of society is the result of a complex interplay between social class, ethnicity, and race, with gender acting as a confounding variable. This social divide serves to isolate the individual from the physical, social, and psychological environments of mainstream society. Social position determines an individual’s social niche, and each niche is associated with its own spectrum of possibilities and limitations, including quality of education and access to healthcare services. Most Americans retain the same social position they had birth, so they essentially live in the same social environment throughout their lifetime; in other words, one is ascribed a social status at birth. Social status determines how the individual is treated in society, and the quality and types of social resources that the individual may access. In particular, the social status of the patient influences a healthcare team’s decision-making process, from diagnosis, to prognosis, and to choice of treatment protocol.
Clinical studies often include the demographics of study subjects, including race, ethnicity, and gender, in the belief that these variables affect the outcome of the research. However, there are those who believe that these variables, on their own, have no significant impact on health, but only in their interaction with socioeconomic factors (Pediatrics, 2000, n.a.). Caution is recommended when drawing inferences regarding the correlation between race, ethnicity, and gender on any given variable under study, because the effect of social status on these other variables can be significant and confound results. For example, according to Williams-Morris (1996), racism has a negative influence on the development of children of color and consequently on their health. However, a study by Smith et al (2005) found that non-Hispanic black children were at higher risk of developing asthma than non-Hispanic white children but only amongst the very poor, suggesting that social and environmental factors pose a higher risk to health than race or ethnicity.
Expanding on those studies, Patcher and Coll (2009) conducted a literature review and applied the social stratification theory to evaluate the correlation between racism and child health. The authors noted that the unequal distribution of health status in children could not be accounted by socioeconomic factors alone but that race and ethnicity play an important role through residential segregation. Physical segregation correlates with the allocation of social, economic, and psychological resources. The economic impact of spatial segregation includes poor living conditions that can lead to unintentional injury and chronic disease. Social resources are scarcer and more difficult to allocate in communities that lack the financial resources to establish organizational programs like those serving more affluent communities.
Poor environmental conditions can lead to low self-esteem that affects the way the individual interacts with society, and may lead to stress, which impacts quality of life and well-being. Children living in these communities are less likely to have proper meals and develop problems related to poor nutrition (Flores et al, 2005). An interesting study would be to evaluate psychological and hereditary factors that might explain how some children manage to succeed in life despite living in these high-risk environments.
In addition to not providing proper nutrition, like consistent daily mealtimes and parental oversight of food consumption, minority parents are less likely to pay attention to environmental safety factors that might impact the health and wellbeing of their children (Flores et al). For example, minority parents are less likely to inspect the environment for possible health hazards, or to install protective devices like stair gates, safety locks, or to take steps to prevent access to dangerous appliances like water heaters or electric fans. Supervision of children is also not optimal and sometimes entirely lacking. Thus, socially disadvantaged minority children tend to inhabit a more dangerous environment, and suffer more injuries due to accidents than children in the general population. Another issue is that minority parents tend to delay or underutilize medical care or to choose traditional medication only after alternative medications have failed; and then, adherence to treatment protocol is rather poor. Thus care of minority children poses a greater challenge to medical healthcare providers.
Lu and Halfton (2003) conducted a study to determine why African American infants have significantly worse birth outcomes than infants from any other racial or ethnic background, regardless of socio-economic background. Typical risk factors that exist during pregnancy, like parental risky behavior, prenatal care, or perinatal infections, did not seem to account for this discrepancy. The authors suggest that early life exposures to risk, not just during pregnancy, may affect the ability to reproduce in the future. In addition, infants who do survive have poorer health outcomes than children in the general population, regardless of risk or protective factors. To complicate matters, some of these child lack access to medical care.
A study on The State Children's Health Insurance Program (SCHIP), a national program for socially disadvantaged children, showed variations in the racial and ethnic composition of the patients enrolled in SCHIP in the various states. Some states enrolled more black children, whereas others enrolled more Hispanic children. However, whatever the racial or ethnic composition, children from minority groups suffered from poorer health status than white children. Part of the reason is that minority children were more likely than white children to have gone uninsured for long periods of time, which means they had little or no access to healthcare during those periods. However, once in the program, there was no significant different in the pattern of healthcare use. The implication of this study is that efforts should be made to reach children who qualify for the program and enroll them earlier in the program in order to provide them with earlier access to medical care. Acute conditions may turn chronic without timely medical intervention.
There are many other issues to consider, including single parenthood, poor physician-patient communication, lack of trust in the healthcare system, and gaps in education. Education is a significant factor that may impact the ability of parents to make the right healthcare choices for their children. Clearly, the risk factors for health disparities are numerous and exert their effect in concert with other factors.
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A study on The State Children's Health Insurance Program (SCHIP), a national program for socially disadvantaged children, showed variations in the racial and ethnic composition of the patients enrolled in the various states. Some states enrolled more black children, whereas others enrolled more Hispanic children. However, whatever the composition, children from minority groups suffered from poorer health status than white children. Part of the reason is that minority children are more likely than white children to have gone uninsured for long periods of time, which means they had little or no access to healthcare during those periods. However, once in the program, there was no significant different in the pattern of healthcare use. The implication of this study is that efforts should be made to reach children who qualify for the program and enroll them earlier in the program to provide them with earlier access to medical care. Acute conditions may turn chronic without timely medical intervention.
Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and <1%; Florida, 16% and 26%; Kansas, 12% and 15%; and New York, 24% and 36%. Black and Hispanic children were more likely to reside in single-parent and lower-income families. With some variation bystate, children from minority groups were more likely to report poorer health status than were white children. Relative to white children, children from minority groups in Florida and New York were more likely to have been uninsured for the entire year before SCHIP enrollment. In all states, children from minority groups who had prior coverage were more likely to have previously been enrolled in Medicaid than in private health insurance and were less likely to have had employer-sponsored coverage compared with white children. Except in Alabama, there was a difference in having a USC, with children from minority groups less likely to have had a USC before SCHIP enrollment compared with white children. No consistent pattern of health care utilization before SCHIP was noted across states with respect to race or ethnicity. Findings from multivariate analyses, controlling for sociodemographic factors, generally confirmed that black and Hispanic children were more likely to have lacked insuranceor a USC before enrollment in SCHIP and to have poorer health status compared with white children.
CONCLUSIONS:
SCHIP is enrolling substantial numbers of racial and ethnic minority children. There arebaseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP: SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnicdisparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIPenrollees can provide a benchmark for evaluating the program's impact on eliminating racial and ethnicdisparities in health and inform service delivery enhancements.
