The Lancet Child & Adolescent Health: Paediatric care for non-White children is universally worse across the USA; policy reform urgently needed to address disparities
The Lancet Child & Adolescent Health: Paediatric care for non-White children is universally worse across the USA; policy reform urgently needed to address disparities
- Two-paper Series identifies pervasive racial inequities in paediatric care in the USA, and outlines policies to address structural racism embedded in wider sectors of society that shape children’s health.
- A review of recent evidence reveals widespread patterns of inequitable care across paediatric specialties, including neonatal care, emergency medicine, surgery, developmental disabilities, mental health care, and palliative care, regardless of health insurance status.
- The authors call for policies to counteract structural racism embedded in society including housing, employment, health insurance, immigration, and the criminal justice system, that could help address health inequities and thereby improve the health of children from racial and minority ethnic groups in the USA. Wide-ranging inequities in paediatric care across specialities
Overcoming these pervasive healthcare inequities – borne of structural racism – requires policy changes in multiple sectors of wider society, including housing, health insurance, and the criminal justice system.
Series author Dr Monique Jindal, of University of Illinois Chicago School of Medicine, said: “There are deeply entrenched racial disparities that span broad sectors of US society and transcend generations. These lead to, among other disadvantages, stark inequities in healthcare for children from minoritised racial and ethnic groups. It is abundantly clear that to ensure every child in the USA receives the best possible healthcare, there is a critical need for far-reaching policy changes that directly address deep-rooted structural racism at its core.” [1]
Wide-ranging inequities in paediatric care across specialities
The Series reveals extensive inequities in care across paediatric specialties, including neonatal care, emergency medicine, and palliative care.
By limiting the review to studies that controlled for health insurance status, the authors identified differences in care quality that are not due to a lack of access to health services.
Evidence from the past five years indicates infants from minoritised racial and ethnic groups, particularly Black and Hispanic children, consistently receive lower-quality neonatal care than White infants. In primary care, there is poorer quality communication between healthcare providers and children, youth and families from minoritized racial and ethnic groups, contributing to persistent inequalities.
Disparities also exist in end-of-life care, the study found. Black, Hispanic, and Asian American children who receive palliative care are more likely to die in the hospital compared to White children. Hispanic children are also more likely to receive medically-intense care during their last days of life.
Differences in wait times, triage assessment, and the evaluation of suspected child abuse for children from minoritised racial and ethnic groups were also found for emergency medicine. The strongest evidence of disparities was in pain management with children from minoritised racial and ethnic groups being less likely than their White peers to receive painkillers for a broken arm or leg, appendicitis, or migraine. The overall trend indicated more care for White patients – such as more painkillers, antibiotics, IV fluids, and diagnostic imaging – even when not justified on medical grounds.
Disparities exist in the diagnosis of developmental disabilities, with Black and Asian children less likely to be diagnosed before preschool or kindergarten as compared to White children, while Latino children with special health care needs receive fewer specialist services than their White peers. There are also inequities in mental health care services, with lower rates of adequate care for major depressive disorder and ADHD among Black, Hispanic, and other children from minoritised racial and ethnic groups compared with White children.
Dr Natalie Slopen, of Harvard University, who led the research review, said, “From the very earliest moments of life, there are pervasive inequities in the quality of healthcare received by children in the USA. Racism profoundly impacts not only children’s health but also people’s health on into adulthood, emphasising the vital importance of tackling disparities in the care received by children.” [1]
Structural and systemic obstacles to equitable paediatric care
Existing policies and practices at the local, state, and federal levels in the USA create and perpetuate structural racism, leading to paediatric health disparities among minoritised racial and ethnic groups. These pose significant obstacles to achieving child health equity and highlight the need for policy solutions that directly address entrenched structural racism.
Housing and neighbourhood policies play a major role in health disparities, as housing instability, poor quality, unaffordability, and neighbourhood characteristics significantly influence children's health outcomes. Racial disparities in housing – which are deeply rooted in historical policies – persist and impact health outcomes, indicating a need for comprehensive strategies to improve social and economic conditions in segregated neighbourhoods.
Economic and employment policies underscore the impact of low socioeconomic status on children's health, with racial income gaps persisting and anti-poverty programs needing an anti-racist approach. Disparities in health insurance access persist, especially for children from minoritised racial and ethnic groups, highlighting the importance of expanding Medicaid and Children’s Health Insurance Program (CHIP) coverage to achieve equity in paediatric health.
The criminal justice system's disproportionate impact on Black people is linked to numerous ill health effects, emphasising the need for policies that prevent young people from going to prison and mitigating the effects on children with parents in prison. Immigration policies also have a significant effect on children's health by determining access to public benefits, with policies enhancing eligibility linked to better paediatric health outcomes.
“We now have more evidence than ever that paediatric care in the USA is not only disparate, but inequitable for a large group of children. Policies that advance health justice and reach across institutions, communities, and populations are urgently needed,” said Series lead Dr Nia Heard-Garris, of the Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University. [1]
Policy reform for healthier children
Based on their analysis, the authors make wide-ranging recommendations for policy changes to counteract pervasive disparities in paediatric care in the USA. “We must fundamentally rethink and redesign systems and policies, not only in healthcare but across the societal spectrum, to promote equitable, excellent health for all children,” said Dr Slopen.
The authors point to numerous changes that could be implemented in broad sectors of society, including measures to improve the social and economic conditions of segregated neighbourhoods, which can benefit child health. Investments in communities can improve access to resources and opportunities, and has been linked to reduced depression and obesity and increased physical activity. Other measures – such as eviction prevention policies – could also ultimately benefit the health of children from racial and minority ethnic backgrounds.
Universal access to health insurance and standardising administrative policies would ultimately deliver greater paediatric health equity. However, there are several areas within health insurance policy that could improve health equity for children more immediately. These include expanding Medicaid/CHIP continuous eligibility beyond 12 months, increasing Medicaid/CHIP provider reimbursement rates, and focusing on social determinants of health.
Enacting policies that set age boundaries to ensure no children are placed in adult prisons can mitigate the heightened risk they face of physical and sexual assault and psychological trauma. In general, policies must reflect that the youth justice system should be used only as a last resort. When it comes to immigration policies, those that increase eligibility for employment, education, and access to resources are also linked with better paediatric health outcomes.
The authors outline several implications of their findings for healthcare practice and policy, including that hospital and other healthcare systems should investigate and address sources of structural racism within their existing policies and guidelines and that senior managers of healthcare systems and providers must take steps to eliminate race-based paediatric care. They also highlight that policy changes to end racial segregation of paediatric care and enhance the diversity of the medical workforce are needed.
The authors also say further research is needed to better characterise the experiences of Asian American and Native American paediatric patients, and children classified as belonging to multiple racial or ethnic groups. Future work should also investigate the intersection of race and ethnicity with other socio-demographic features, such as gender identity, sexual orientation, and family immigration history.
NOTES TO EDITORS
The review paper was funded by the CZI/Silicon Valley Community Foundation, Eunice Kennedy Shriver National Institute for Child Health and Human Development, National Institutes of Health, and National Heart Lung and Blood Institute. It was conducted by researchers from Harvard University, University of California, Davis, University of Southern California, Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago, University of Illinois Chicago, University of Minnesota, Thomas Jefferson University, Australian National University, and Emory University.
The policy paper was funded by the National Institutes of Health. It was conducted by researchers from University of Illinois Chicago, University of California, Los Angeles, University of Minnesota, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Northeastern University, ohns Hopkins University School of Medicine, US Department of Health and Human Services, Harvard University, Emory University, and Brigham and Women’s Hospital, Boston.
[1] Quote direct from author and cannot be found in the text of the Article.
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JOURNAL
The Lancet Child & Adolescent Health
METHOD OF RESEARCH
Literature review
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Racism and child health in the USA
ARTICLE PUBLICATION DATE
17-Jan-2024
COI STATEMENT
Paper 1: AC has a contract with Organon & Co (previously part of Merck) as a clinical trainer for the Nexplanon contraceptive device. In this role, she Search strategy and selection criteria We searched PubMed for human studies published in English from Jan 1, 2017, to July 31, 2022, using the search terms ((“Race Factors”[Mesh] OR ethnic* OR minorit* OR race* OR racial OR “race/ethnic” OR “racial/ethnic” OR “racial disparit*” OR “ethnic disparit*” OR “ethnic difference*” OR “racial difference*” OR “race difference*”) AND ((Healthcare Disparities[mesh] OR (healthcare disparit*) AND (quality OR “Quality of Health Care”[Mesh])) AND (Adolescent[mesh] OR Child[mesh] OR Infant[mesh] OR Pediatrics[mesh] OR (adoles* OR child* OR infan* OR paed* OR pediatr* OR teen* OR youth*))). In addition, we reviewed the reference lists from the identified articles and our personal reference libraries. We included quantitative studies of children and adults younger than 21 years set in the USA. The selected studies had a primary objective to compare at least one health-care quality outcome between two or more racial or ethnic groups and adjusted for or stratified by insurance status or restricted enrolment to a single payor type (eg, Medicaid). The final reference list was generated based on these criteria and relevance to the broad scope of our review. www.thelancet.com/child-adolescent Vol 8 February 2024 155 Series provides training and education to resident physicians at her institution in the use of the subdermal implant device. She does not receive payment or any other form of incentive from Organon & Co in this role. NH-G is the co-owner of XNY Genes. All other authors declare no competing interests. Paper 2: AC has a contract with Organon & Co (previously part of Merck) as a clinical trainer for the Nexplanon contraceptive device. In this role, she provides training and education to resident physicians at her institution in the use of the subdermal implant device. She does not receive payment or any other form of incentive from Organon & Co in this role NH-G is the co-owner of XNY Genes. All other authors declare no competing interests.
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