Technical report--racial and ethnic disparities in the health and health care of children

Racial and Ethnic Disparities among Pediatric Patients at Community Health Centers

OBJECTIVES

To assess racial/ethnic disparities in pediatric utilization of community health centers (CHCs) among a nationally representative sample.

STUDY DESIGN

Using the 2009 Health Center Patient Survey, a nationally representative sample of CHC patients, demographic characteristics, health conditions, and service utilization were examined for patients under 18 years old (n = 590). Negative binomial and logistic regression models assessed disparities in access to routine care, ambulatory service intensity, and hospital utilization.

RESULTS

Racial/ethnic disparities were not present for well-child visits or dental checkups. However, disparities in ambulatory care service intensity and hospital use were observed. Compared with white children, Hispanic children had fewer CHC visits (incidence rate ratio [IRR] 0.62; 95% CI 0.41-0.95), and fewer visits to other ambulatory providers (IRR 0.30; 95% CI 0.15-0.61). Black children had fewer CHC visits (IRR 0.46; 95% CI 0.31-0.70) and fewer visits to other ambulatory providers (IRR 0.23; 95% CI 0.06-0.91), and were also less likely to have been hospitalized (OR 0.04; 95% CI 0.01-0.26).

CONCLUSIONS

Study limitations included the cross-sectional study design, the self-reported data, and the age of the data. Nevertheless, this study demonstrates that there are fewer disparities among children who visit CHCs in comparison with national trends, but there is still room for improvement. Future initiatives should address remaining challenges in ensuring access to care for all children in underserved communities.

Disparities in Quality of Healthcare of Children from Immigrant Families in the US

The objective of this study was to examine disparities in quality of pediatric primary care among children from immigrant families in the US. Drawing from a nationally representative sample of 83,528 children ages 0-17 years from the 2007 National Survey of Children's Health, weighted logistic regression was used to assess the effect of immigrant family type on five indicators of quality of healthcare across children's racial/ethnic groups. Analyses controlled for indicators of child's access to care, family socio-economic characteristics, and primary language spoken in the household. Unadjusted estimates revealed a pattern of decreasing disparities from immigrant children to second-generation children, native-born children of immigrant parents, and to third-generation children, native-born children of native-born parents. Controlling for confounders showed that the positive effect of generational status on the quality of healthcare of children from immigrant families varied across indicators and among racial/ethnic groups. Not even third-generation Hispanic and Black children reached parity with third-generation White children on reported amount of time that providers devoted to their care and on providers' sensitivity to their family's values and customs. In contrast, disparities in reports of providers listening carefully to caregivers disappeared after adjusting for confounders, and only families headed by immigrant parents reported receiving less specific health-related information than the families of native-born White children. Our study suggests that it is important to develop interventions that help healthcare professionals to learn how different types of immigrant families perceive the interactions with the healthcare system and how to deliver care that increases the satisfaction of children from different racial/ethnic groups.

Topical Review: Provider-Patient Interactions: An Important Consideration for Racial/Ethnic Health Disparities in Youth

OBJECTIVE

To summarize literature on the role of provider-patient interactions (PPI) in racial/ethnic health disparities and consider the relevance of PPI for understanding health disparities in pediatric psychology.

METHODS

Topical review of literature focusing on health disparities and PPI in adult and pediatric populations.

RESULTS

For adults, evidence is clear that racial/ethnic minorities experience poorer quality PPI, which may be associated with poorer health outcomes. In pediatric populations, the emerging literature indicates similar associations, and potential promising targets for intervention including information exchange, shared decision-making and patient-centered communication. PPI research in pediatric populations poses a number of methodological challenges including culturally and developmentally sensitive measurement of triadic (caregiver, patient, provider) interactions.

CONCLUSIONS

Health disparities in PPI exist for racial/ethnic minority youth and may contribute to poorer health outcomes. Pediatric psychologists can make valuable contributions, given their expertise and role within medical settings. Research, clinical, and policy recommendations are discussed.

Racial/Ethnic Differences in Pediatric Brain Tumor Diagnoses in Patients with Neurofibromatosis Type 1

OBJECTIVE

To evaluate evidence for differences in pediatric brain tumor diagnoses by race and ethnicity using a cross-sectional study design in individuals with neurofibromatosis type 1 (NF1).

STUDY DESIGN

Subjects with NF1 were ascertained from the NF1 Patient Registry Initiative and through a clinical record database of patients at a large academic medical center. Logistic regression was employed to calculate ORs and 95% CIs to analyze differences in the odds of brain tumor diagnosis by race (White, Black, Asian, other/unknown) and ethnic (Hispanic vs non-Hispanic) groups.

RESULTS

Data from a total of 1546, 629, and 2038 individuals who were ascertained from the NF1 Patient Registry Initiative, clinical records, and pooled datasets were analyzed, respectively. After adjusting for birth year, we observed a significantly reduced odds of brain tumor diagnoses in individuals self-identified or clinically reported as Black (OR = 0.13, 95% CI 0.05-0.31), Asian (OR = 0.15, 95% CI 0.04-0.64), and other/unknown (OR = 0.61, 95% CI 0.41-0.93) race compared with those with reported as White race. There was no significant difference in the odds of pediatric brain tumor diagnosis by Hispanic ethnicity.

CONCLUSIONS

Consistent with prior smaller studies, these data suggest that pediatric brain tumor diagnoses vary by race in individuals with NF1. Reasons underlying observed differences by race warrant further investigation.

Participation in pediatric oncology research protocols: Racial/ethnic, language and age-based disparities

BACKGROUND

Survival rates in pediatric oncology have improved dramatically, in part due to high patient participation in clinical trials. Although racial/ethnic inequalities in clinical trial participation have been reported in adults, pediatric data and studies comparing participation rates by socio-demographic characteristics are scarce. The goal of this study was to assess differences in research protocol participation for childhood cancer by age, sex, race/ethnicity, parental language, cancer type, and insurance status.

PROCEDURE

Data on enrollment in any protocol, biospecimen, or therapeutic protocols were collected and analyzed for newly diagnosed pediatric patients with cancer from 2008-2012 at Rady Children's Hospital.

RESULTS

Among the 353 patients included in the analysis, 304 (86.1%) were enrolled in any protocol. Enrollment in biospecimen and therapeutic protocols was 84.2% (261/310) and 81.1% (206/254), respectively. Logistic regression analyzes revealed significant enrollment underrepresentation in any protocol for Hispanics compared to Non-Hispanic whites (81% vs. 91%; Odds Ratio [OR], 0.43; 95% Confidence Interval [CI], 0.21-0.90; P = 0.021) and among children of Spanish-speaking vs. English-speaking parents (78% vs. 89%; OR, 0.45; 95%CI, 0.23-0.87; P = 0.016). Compared to patients aged 0-4 years, significant underrepresentation was also found among patients 15-21 years old (92% vs.72%; OR, 0.21; 95% CI, 0.09-0.48; P < 0.001). Similar trends were observed when analyzing enrollment in biospecimen and therapeutic protocols separately.

CONCLUSIONS

There was significant underrepresentation in protocol participation for Hispanics, children of Spanish-speaking parents, and patients ages 15-21. Research is needed to understand barriers to research participation among these groups underrepresented in pediatric oncology clinical trials.

Racial/ethnic differences in parent-reported barriers to accessing children's health services

The goals of this study were to identify whether barriers that parents perceived to using health care differed by service type (medical vs. mental health care) and whether there were racial/ethnic differences in barriers. Participants were a community sample of 275 parents (34.2% African American, 36.7% Caucasian, and 29.1% Hispanic) of children ages 9-13 years old who rated the extent to which potential barriers in 3 broad domains (stigma-related, logistical, and socioeconomic) would prevent or delay them from obtaining services. They also rated internalizing and externalizing problems exhibited by their child. Overall, parents reported greater socioeconomic and stigma-related barriers to obtaining mental health services than medical services. Hispanic parents reported socioeconomic and stigma-related barriers as more inhibiting than did African-American parents. Findings highlight the importance of strengthening relationships between mental health care providers and the community to reduce the stigma associated with seeking mental health treatment for children and better educating parents about the potential benefits of treatment. Policy focused on educating parents about their insurance options and improving insurance coverage may help to reduce socioeconomic barriers.

Effects of prenatal factors and temperament on infant cortisol regulation in low-income Mexican American families

Prenatal psychosocial exposures can significantly affect infant health and development. Infants with higher temperamental negativity are theorized to be more susceptible to environmental exposures. We evaluated the interaction of prenatal maternal exposures and infant temperamental negativity to predict infant cortisol response to mildly challenging mother-infant interaction tasks. Participants included 322 Mexican American mother-infant dyads (mother age 18-42; 82% Spanish-speaking; modal family income $10,000-$15,000). Mothers reported depressive symptoms and social support prenatally and infant temperamental negativity at 6 weeks postpartum. Salivary cortisol was collected from infants before and after mother-infant interaction tasks at 12 weeks. Higher prenatal maternal depressive symptoms and lower social support predicted higher cortisol among infants with higher temperamental negativity. Higher infant temperamental negativity predicted an increase in maternal distress and a decrease in social support from prenatal to 12 weeks postpartum. Interactive influences of maternal social-contextual factors and infant temperament may influence the development of infant neurobiological regulation and promote or strain maternal and infant adaptation over time.

Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study

OBJECT Sport-related concussion (SRC) is a major public health problem. Approximately 90% of SRCs in high school athletes are transient; symptoms recover to baseline within 1 week. However, a small percentage of patients remain symptomatic several months after injury, with a condition known as postconcussion syndrome (PCS). The authors aimed to identify risk factors for PCS development in a cohort of exclusively young athletes (9-18 years of age) who sustained SRCs while playing a sport. METHODS The authors conducted a retrospective case-control study by using the Vanderbilt Sports Concussion Clinic database. They identified 40 patients with PCS and matched them by age at injury and sex to SRC control patients (1 PCS to 2 control). PCS patients were those experiencing persistent symptoms at 3 months after an SRC. Control patients were those with documented resolution of symptoms within 3 weeks of an SRC. Data were collected in 4 categories: 1) demographic variables; 2) key medical, psychiatric, and family history; 3) acute-phase postinjury symptoms (at 0-24 hours); and 4) subacute-phase postinjury features (at 0-3 weeks). The chi-square Fisher exact test was used to assess categorical variables, and the Mann-Whitney U-test was used to evaluate continuous variables. Forward stepwise regression models (Pin = 0.05, Pout = 0.10) were used to identify variables associated with PCS. RESULTS PCS patients were more likely than control patients to have a concussion history (p = 0.010), premorbid mood disorders (p = 0.002), other psychiatric illness (p = 0.039), or significant life stressors (p = 0.036). Other factors that increased the likelihood of PCS development were a family history of mood disorders, other psychiatric illness, and migraine. Development of PCS was not predicted by race, insurance status, body mass index, sport, helmet use, medication use, and type of symptom endorsement. A final logistic regression analysis of candidate variables showed PCS to be predicted by a history of concussion (OR 1.8, 95% CI 1.1-2.8, p = 0.016), preinjury mood disorders (OR 17.9, 95% CI 2.9-113.0, p = 0.002), family history of mood disorders (OR 3.1, 95% CI 1.1-8.5, p = 0.026), and delayed symptom onset (OR 20.7, 95% CI 3.2-132.0, p < 0.001). CONCLUSIONS In this age- and sex-matched case-control study of risk factors for PCS among youth with SRC, risk for development of PCS was higher in those with a personal and/or family history of mood disorders, other psychiatric illness, and migraine. These findings highlight the unique nature of SRC in youth. For this population, providers must recognize the value of establishing the baseline health and psychiatric status of children and their primary caregivers with regard to symptom reporting and recovery expectations. In addition, delayed symptom onset was an unexpected but strong risk factor for PCS in this cohort. Delayed symptoms could potentially result in late removal from play, rest, and care by qualified health care professionals. Taken together, these results may help practitioners identify young athletes with concussion who are at a greater danger for PCS and inform larger prospective studies for validation of risk factors from this cohort.

Minorities are Disproportionately Underrepresented in Special Education: Longitudinal Evidence Across Five Disability Conditions

We investigated whether and to what extent minority children attending elementary and middle schools in the U.S. are over- or under-identified as disabled and so disproportionately represented in special education. To address existing limitations in the field's knowledge base, we (a) analyzed multi-year longitudinal data, (b) used hazard modeling to estimate over-time dynamics of disability identification across five specific conditions, and (c) extensively corrected for child-, family-, and school-level potential confounding variables (e.g., child-level academic achievement and behavior, family-level socioeconomic status, school-level state location). Despite long-standing and on-going federal legislative and policy efforts to reduce minority over-representation in special education, our analyses indicated that this has not been occurring in the U.S. Instead, minority children are less likely than otherwise similar White, English-speaking children to be identified as disabled and so receive special education services. From kindergarten entry to at least the end of middle school, racial and ethnic minority children are less likely than otherwise similar White children to be identified as having (a) learning disabilities, (b) speech or language impairments, (c) intellectual disabilities, (d) health impairments, or (d) emotional disturbances. Language minority children are less likely to be identified as having (a) specific learning disabilities or (b) speech or language impairments.

Unexpected deaths and unplanned re-admissions in infants discharged home after cardiac surgery: a systematic review of potential risk factors

BACKGROUND

Babies with CHDs are a particularly vulnerable population with significant mortality in their 1st year. Although most deaths occur in the hospital within the early postoperative period, around one-fifth of postoperative deaths in the 1st year of life may occur after hospital discharge in infants who have undergone apparently successful cardiac surgery. Aim To systematically review the published literature and identify risk factors for adverse outcomes, specifically deaths and unplanned re-admissions, following hospital discharge after infant surgery for life-threatening CHDs.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and PsycINFO electronic databases, supplemented by manual searching of conference abstracts.

RESULTS

A total of 15 studies were eligible for inclusion. Almost exclusively, studies were conducted in single US centres and focussed on children with complex single ventricle diagnoses. A wide range of risk factors were evaluated, and those more frequently identified as having a significant association with higher mortality or unplanned re-admission risk were non-Caucasian ethnicity, lower socio-economic status, co-morbid conditions, age at surgery, operative complexity and procedure type, and post-operative feeding difficulties.

CONCLUSIONS

Studies investigating risk factors for adverse outcomes post-discharge following diverse congenital heart operations in infants are lacking. Further research is needed to systematically identify higher risk groups, and to develop interventions targeted at supporting the most vulnerable infants within an integrated primary and secondary care pathway.

The Culturally-Enhanced Videofeedback Engagement (CEVE) Framework: Qualitative findings in families of children with disruptive behavior problems

While cultural competence has been promoted as a way to reduce mental health disparities among ethnic minority populations, there remains a gap between theory and practice. This study examined the use of the Culturally Enhanced Videofeedback Engagement (CEVE) intervention as a clinical tool to facilitate culturally anchored shared understanding to foster treatment engagement among ethnic minority families with children with disruptive behavior disorders (DBDs) participating in a family clinic. In-depth qualitative analysis of individual interviews compared parents' experiences of the therapy process among 9 intervention families and 10 families participating in treatment as usual. Thematic analysis of semistructured interviews with parents revealed that for families in the intervention group, clinician cultural and clinical competence and the therapeutic relationship were important characteristics of the intervention condition that enhanced parents' experience of treatment.

Racial and socioeconomic disparities in outcomes following pediatric cerebrospinal fluid shunt procedures

OBJECT Racial and socioeconomic disparities within the US health care system are a growing concern. Despite extensive research and efforts to narrow such disparities, minorities and economically disadvantaged patients continue to exhibit inferior health care outcomes. Disparities in the delivery of pediatric neurosurgical care are understudied. Authors of this study examine the impact of race and socioeconomic status on outcomes following pediatric CSF shunting procedures. METHODS Discharge information from the 2000, 2003, 2006, and 2009 Kids' Inpatient Database for individuals (age < 21 years) with a diagnosis of hydrocephalus who had undergone CSF shunting procedures was abstracted for analysis. Multivariate logistic regression analyses, adjusting for patient and hospital factors and annual CSF shunt procedure volume, were performed to evaluate the effects of race and payer status on the likelihood of inpatient mortality and nonroutine hospital discharge (that is, not to home). RESULTS African American patients (p < 0.05) had an increased likelihood of inpatient death and nonroutine discharge compared with white patients. Furthermore, Medicaid patients had a significantly higher likelihood of nonroutine discharge (p < 0.05) as compared with privately insured patients. CONCLUSIONS Findings in this study, which utilized US population-level data, suggest the presence of racial and socioeconomic status outcome disparities following pediatric CSF shunting procedures. Further studies on health disparities in this population are warranted.

Discrimination, racial identity, and cytokine levels among African-American adolescents

PURPOSE

Low-grade inflammation, measured by circulating levels of cytokines, is a pathogenic mechanism for several chronic diseases of aging. Identifying factors related to inflammation among African-American youths may yield insights into mechanisms underlying racial disparities in health. The purpose of the study was to determine whether (1) reported racial discrimination from ages 17-19 years forecasts heightened cytokine levels at the age of 22 years and (2) this association is lower for youths with positive racial identities.

METHODS

A longitudinal research design was used with a community sample of 160 African-Americans who were aged 17 years at the beginning of the study. Discrimination and racial identity were measured with questionnaires, and blood was drawn to measure basal cytokine levels. Ordinary least squares regression analyses were used to examine the hypotheses.

RESULTS

After controlling for socioeconomic risk, life stress, depressive symptoms, and body mass index, racial discrimination (β = .307; p < .01), racial identity (β = -.179; p < .05), and their interaction (β = -.180; p < .05) forecast cytokine levels. Youths exposed to high levels of racial discrimination evinced elevated cytokine levels 3 years later. This association was not significant for young adults with positive racial identities.

CONCLUSIONS

High levels of interpersonal racial discrimination and the development of a positive racial identity operate jointly to determine low-grade inflammation levels that have been found to forecast chronic diseases of aging, such as coronary disease and stroke.

Parent health beliefs, social determinants of health, and child health services utilization among U.S. school-age children with autism

OBJECTIVE

Substantial variation exists in autism spectrum disorder (ASD) care by race, ethnicity, and socioeconomic status; however, the role of parent health beliefs in this variation is poorly understood. Study goals were to (1) examine variation in parent beliefs about ASD prognosis and treatment according to social determinants of health (SDH) and (2) assess whether this variation was associated with variable health services utilization, among 1420 children with special health care needs (CSHCN) having ASD.

METHODS

We used linked data from the 2011 Survey of Pathways to Diagnosis and Treatment and the 2009-2010 National Survey of Children with Special Health Care Needs. Bivariate and multivariate analyses assessed variation in parent beliefs according to race/ethnicity, household income, and parent educational attainment. Further analyses assessed whether variation in beliefs was associated with the use of psychotropic medication, traditional therapy, or complementary/alternative therapy for ASD.

RESULTS

Parents of lower educational attainment or who had lower income were more likely to think that their child's condition was a mystery. Near-poor families were less likely to believe that they had the power to change the child's condition. Parents of minority children were more likely than white children to view their child's condition as temporary. However, these differences in beliefs only had modest associations with variation in use of the health services analyzed.

CONCLUSIONS

Some SDH-related variation exists in health beliefs among parents of children with ASD, but these differences may not be the main factors accounting for ASD health care disparities.

Vision and eye health in children 36 to <72 months: proposed data definitions

Supplemental digital content is available in the text.

Purpose

To recommend a standardized approach for measuring progress toward national goals to improve preschool children’s eye health.

Methods

A multidisciplinary panel of experts reviewed existing measures and national vision-related goals during a series of face-to-face meetings and conference calls. The panel used a consensus process, informed by existing data related to delivery of eye and non-eye services to preschool children.

Results

Currently, providers of vision screening and eye examinations lack a system to provide national- or state-level estimates of the proportion of children who receive either a vision screening or an eye examination. The panel developed numerator and denominator definitions to measure rates of children “who completed a vision screening in a medical or community setting using a recommended method, or received an eye examination by an optometrist or ophthalmologist at least once between the ages of 36 to <72 months.” A separate measure for children with neurodevelopmental disorders and measures for eye examination and follow-up were also developed. The panel recommended that these measures be implemented at national, state, and local levels.

Conclusions

Standardized performance measures that include all eye services received by a child are needed at state and national levels to measure progress toward improving preschool children’s eye health.

Health among Black children by maternal and child nativity

OBJECTIVES

We examined 5 health outcomes among Black children born to US-born and foreign-born mothers and whether differences by mother's region of birth could be explained by maternal duration of US residence, child's place of birth, and familial sociodemographic characteristics.

METHODS

Data were from the 2000-2011 National Health Interview Surveys. We examined 3 groups of children, based on mother's region of birth: US origin, African origin, and Latin American or Caribbean origin. We estimated multivariate regression models.

RESULTS

Children of foreign-born mothers were healthier across all 5 outcomes than were children of US-born mothers. Among children of foreign-born mothers, US-born children performed worse on all health outcomes than children born abroad. African-origin children had the most favorable health profile. Longer duration of US residence among foreign-born mothers was associated with poorer child health. Maternal educational attainment and other sociodemographic characteristics did little to explain these differences.

CONCLUSIONS

Further studies are needed to understand the role of selective migration and the behavioral, cultural, socioeconomic, and contextual origins of the health advantage of Black children of foreign-born mothers.

Regional and socioeconomic disparities in emergency department use of radiographic imaging for acute pediatric sinusitis

BACKGROUND

Acute pediatric sinusitis (APS) is a common complication of pediatric upper respiratory tract infections. Children with all degrees of APS severity may present to emergency departments (EDs) for evaluation and management. This study was designed to analyze the use of imaging in APS presenting to U.S. EDs.

METHODS

A cross-sectional analysis of the 2008 National Emergency Department Sample database was performed. One hundred one thousand six hundred sixty children, aged ≤18 years, assigned at least one ICD9 code for APS were identified. Current procedural terminology codes for sinus plain film radiographs, computed tomography (CT), and magnetic resonance imaging identified children who underwent sinus imaging. Association of performance of sinus imaging was sought with multiple predictor variables including clinicodemographic and hospital characteristics.

RESULTS

The use of any imaging was associated with older age (odds ratio [OR] = 1.07; p < 0.001), male gender (OR = 1.57; p < 0.001), and diagnosis of chronic rhinosinusitis (OR = 2.46; p < 0.001). Imaging was more common in metropolitan teaching (OR = 1.40;0 p < 0.001) and nonteaching (OR = 5.64; p < 0.001) hospitals. Markers of higher socioeconomic status--private health insurance (OR = 1.37; p < 0.001) and higher income level (OR = 1.96; p < 0.001)--were associated with greater use of imaging, especially CT scans.

CONCLUSION

The use of ED imaging in APS is appropriately associated with factors known to be associated with APS complications. However, additional disparities with respect to regional and socioeconomic factors exist. Interventions to eliminate these health care disparities in use of imaging resources may lead to quality improvement in care and outcomes for APS.

Health-related hindrance of personal goals of adolescents with cancer: The role of the interaction of race/ethnicity and income

This study examined the interaction of race/ethnicity and income to health-related hindrance (HRH) of personal goals of adolescents with cancer. Adolescents (N = 94) receiving treatment for cancer completed a measure of HRH, (including identification of personal goals, rating the impact of health on goal pursuit, and ratings of goal appraisals). The interaction of race/ethnicity and income on HRH was examined. Goal content and appraisal were compared by race/ethnic groups. The interaction between race/ethnicity and income was significant in predicting HRH, with HRH increasing for minority adolescents as income increases and HRH decreasing for white adolescents as income increases. Higher income minority adolescents reported the most goals. Low income minorities reported the least difficult goals. Goal content did not differ between groups. Sociodemographic factors contribute to HRH in adolescents with cancer. Structural and psychosocial support during treatment to maintain goal pursuit may improve psychosocial outcomes.

Patient- and family-centered care of children in the emergency department

Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This revised technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care.

Race, ethnicity, and socioeconomic status in research on child health

An extensive literature documents the existence of pervasive and persistent child health, development, and health care disparities by race, ethnicity, and socioeconomic status (SES). Disparities experienced during childhood can result in a wide variety of health and health care outcomes, including adult morbidity and mortality, indicating that it is crucial to examine the influence of disparities across the life course. Studies often collect data on the race, ethnicity, and SES of research participants to be used as covariates or explanatory factors. In the past, these variables have often been assumed to exert their effects through individual or genetically determined biologic mechanisms. However, it is now widely accepted that these variables have important social dimensions that influence health. SES, a multidimensional construct, interacts with and confounds analyses of race and ethnicity. Because SES, race, and ethnicity are often difficult to measure accurately, leading to the potential for misattribution of causality, thoughtful consideration should be given to appropriate measurement, analysis, and interpretation of such factors. Scientists who study child and adolescent health and development should understand the multiple measures used to assess race, ethnicity, and SES, including their validity and shortcomings and potential confounding of race and ethnicity with SES. The American Academy of Pediatrics (AAP) recommends that research on eliminating health and health care disparities related to race, ethnicity, and SES be a priority. Data on race, ethnicity, and SES should be collected in research on child health to improve their definitions and increase understanding of how these factors and their complex interrelationships affect child health. Furthermore, the AAP believes that researchers should consider both biological and social mechanisms of action of race, ethnicity, and SES as they relate to the aims and hypothesis of the specific area of investigation. It is important to measure these variables, but it is not sufficient to use these variables alone as explanatory for differences in disease, morbidity, and outcomes without attention to the social and biologic influences they have on health throughout the life course. The AAP recommends more research, both in the United States and internationally, on measures of race, ethnicity, and SES and how these complex constructs affect health care and health outcomes throughout the life course.

Black versus white differences in rates of addressing parental tobacco use in the pediatric setting

OBJECTIVE

To examine racial differences in rates of screening parents for cigarette smoking during pediatric outpatient visits and to determine if a parental tobacco control intervention mitigates racial variation in whether cigarette smoking is addressed.

METHODS

As part of the Clinical Effort Against Secondhand Smoke Exposure (CEASE) randomized controlled trial, exit interviews were conducted with parents at 10 control and 10 intervention pediatric practices nationally. Parents were asked to report if during the visit did anyone ask if they smoke cigarettes. A generalized linear mixed model was used to estimate the effect of black vs white race on asking parents about cigarette smoking.

RESULTS

Among 17,692 parents screened at the exit interview, the proportion of black parents who were current smokers (16%) was lower than the proportion of white parents who smoked (20%) (P < .001). In control group practices, black parents were more likely to be asked (adjusted risk ratio 1.23; 95% confidence interval 1.08, 1.40) about cigarette smoking by pediatricians than whites. In intervention group practices both black and white parents were more likely to be asked about smoking than those in control practices and there was no significant difference between black and white parents in the likelihood of being asked (adjusted risk ratio 1.01; 95% confidence interval 0.93, 1.09).

CONCLUSIONS

Although a smaller proportion of black parents in control practices smoked than white, black parents were more likely to be asked by pediatricians about smoking. The CEASE intervention was associated with higher levels of screening for smoking for both black and white parents.

Satisfaction with care and decision making among parents/caregivers in the pediatric intensive care unit: a comparison between English-speaking whites and Latinos

PURPOSE

Because of previously documented health care disparities, we hypothesized that English-speaking Latino parents/caregivers would be less satisfied with care and decision making than English-speaking non-Latino white (NLW) parents/caregivers.

MATERIALS AND METHODS

An intensive care unit (ICU) family satisfaction survey, Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version), was completed by English-speaking parents/caregivers of children in a cardiothoracic ICU at a university-affiliated children's hospital in 2011. English-speaking NLW and Latino parents/caregivers of patients, younger than 18 years, admitted to the ICU were approached to participate on hospital day 3 or 4 if they were at the bedside for greater than or equal to 2 days. Analysis of variance, χ(2), and Student t tests were used. Cronbach αs were calculated.

RESULTS

Fifty parents/caregivers completed the survey in each group. Latino parents/caregivers were younger, more often mothers born outside the United States, more likely to have government insurance or no insurance, and had less education and income. There were no differences between the groups' mean overall satisfaction scores (92.6 ± 8.3 and 93.0 ± 7.1, respectively; P = .80). The Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version) showed high internal consistency reliability (α = .95 and .91 for NLW and Latino groups, respectively).

CONCLUSIONS

No disparities in ICU satisfaction with care and decision making between English-speaking NLW and Latino parents/caregivers were found.

Food and Beverage Marketing to Youth

After nearly a decade of concern over the role of food and beverage marketing to youth in the childhood obesity epidemic, American children and adolescents - especially those from communities of color - are still immersed in advertising and marketing environments that primarily promote unhealthy foods and beverages. Despite some positive steps, the evidence shows that the food and beverage industry self-regulation alone is not likely to significantly reduce marketing of unhealthy foods and beverages to youth. A variety of research is needed to monitor industry marketing of unhealthy products to young people, and identify the most promising approaches to improve children's food marketing environments. The continued presence of unhealthy marketing toward children despite years of industry self-regulation suggests it is time for stronger action by policymakers to protect young people from harmful marketing practices.

Race and health disparities in adults with intellectual and developmental disabilities living in the United States

Research has documented disparities in health care and access for people with intellectual and developmental disabilities (IDD) and people in racial and ethnic minority groups. Though both populations are underserved, the additive impact of being both a member of a racial/ethnic minority and having IDD is largely unknown. This study uses data from a nationally representative survey to explore health service utilization among adults with IDD belonging to minority racial/ethnic groups compared to adults with IDD who are White. The results of this study indicated that racial/ethnic minority groups are disadvantaged in several essential areas of health care utilization and that Hispanic Americans are particularly underserved. Additional research is needed to identify and address the factors driving this difference.

Differences in Access to Care Among Students Using School-Based Health Centers

Health care reform has changed the landscape for the nation's health safety net, and school-based health centers (SBHCs) remain an important part of this system. However, few large-scale studies have been conducted to assess their impact on access to care. This study investigated differences in access among a nationally representative sample of adolescent SBHC users. An analysis using multivariate logistic regression examined the association between student characteristics and access to care. We found no differences based on race/ethnicity or insurance status among adolescent SBHC users; however, we did observe significant differences with regard to unmet health needs. School nurses serve as invaluable frontline staff who can facilitate equitable access to care, provide high-quality primary care, coordinate care for students with community health services, and advocate for policy and funding support of SBHCs as a critical part of the safety net for underserved adolescents.

Obesity and asthma: pathophysiology and implications for diagnosis and management in primary care

The effects of obesity on asthma diagnosis, control, and exacerbation severity are increasingly recognized; however, the underlying pathophysiology of this association is poorly understood. Mainstream clinical practice has yet to adopt aggressive management of obesity as a modifiable risk factor in asthma care, as is the case with a risk factor like tobacco or allergen exposure. This review summarizes existing data that support the pathophysiologic mechanisms underlying the association between obesity and asthma, as well as the current and future state of treatment for the obese patient with asthma. Our review suggests that evidence of chronic inflammatory response linking obesity and asthma indicates a need to address obesity during asthma management, possibly using patient-centered approaches such as shared decision making. There is a need for research to better understand the mechanisms of asthma in the obese patient and to develop new therapies specifically targeted to this unique patient population.

Conceptualization of autism in the Latino community and its relationship with early diagnosis

OBJECTIVE

Early identification of autism spectrum disorders (ASD) has been linked to improved long-term developmental outcomes. However, Latino children are diagnosed later than white non-Latino children. We aimed to qualitatively assess the understanding and conceptualization of ASD in the Latino community to understand potential community barriers to early diagnosis.

METHODS

We conducted 5 focus groups and 4 qualitative interviews with 30 parents of typically developing Latino children in Oregon. Participants were asked structured questions concerning video vignettes that follow a Latina mother from the time she begins to worry about her 3-year-old son's behaviors to the time he receives an ASD diagnosis. Focus groups and interviews were audio-recorded, transcribed, and independently coded. Coded data were analyzed using thematic analysis.

RESULTS

Many Latino families in the study had not heard of ASD or had little information about it. Families sometimes assumed that ASD red flags were normal or could be attributed to family dysfunction. Families also had concerns about provider communication and access to language services. Having a child with a developmental delay was associated with embarrassment, rejection, and family burden, making it difficult for parents to raise developmental concerns with providers.

CONCLUSIONS

Pediatric providers should not assume that Latino parents have heard of ASD or know its symptoms. Providers should be aware that parents may be reluctant to mention concerns because of cultural factors. The health care system needs to improve resources for Latino parents with limited English proficiency. Policies should encourage the use of developmental screening in primary care.

Measuring early childhood health and health disparities: a new approach

Efforts to improve the health of U.S. children and reduce disparities have been hampered by lack of a rigorous way to summarize the multi-dimensional nature of children's health. This research employed a novel statistical approach to measurement to provide an integrated, comprehensive perspective on early childhood health and disparities. Nationally-representative data (n = 8,800) came from the Early Childhood Longitudinal Study, Birth Cohort. Latent class analysis was used to classify health at 48 months, incorporating health conditions, functioning, and aspects of physical, cognitive, and emotional development. Health disparities by gender, poverty, race/ethnicity, and birthweight were examined. Over half of all children were classified as healthy using multidimensional latent class methodology; others fell into one of seven less optimal health statuses. The analyses highlighted pervasive disparities in health, with poor children at increased risk of being classified into the most disadvantaged health status consisting of chronic conditions and a cluster of developmental problems including low cognitive achievement, poor social skills, and behavior problems. Children with very low birthweight had the highest rate of being in the most disadvantaged health status (25.2 %), but moderately low birthweight children were also at elevated risk (7.9 vs. 3.4 % among non-low birthweight children). Latent class analysis provides a uniquely comprehensive picture of child health and health disparities that identifies clusters of problems experienced by some groups. The findings underscore the importance of continued efforts to reduce preterm birth, and to ameliorate poverty's effects on children's health through access to high-quality healthcare and other services.

Racial/ethnic disparities in ADHD diagnosis by kindergarten entry

BACKGROUND

Whether and to what extent racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis occur by kindergarten entry is currently unknown. We investigated risk factors associated with an ADHD diagnosis by kindergarten entry generally, and specifically whether racial/ethnic disparities in ADHD diagnosis occur by this very early time period.

METHODS

Secondary analysis of data from children enrolled in the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B), a large, nationally representative cohort of U.S. children born in 2001. Data include information from birth certificates, parent and teacher questionnaires, and in-person developmental assessments conducted with children at intervals from 9 months through kindergarten entry. The analytic sample included children enrolled in the ECLS-B at the 60-month assessment (N = 6,550).

RESULTS

Black children in the United States were 70% (1 - OR of .30) less likely to receive an ADHD diagnosis than otherwise similar White children. Hispanic children initially appeared to be underdiagnosed for ADHD. However, their disparity with Whites became statistically nonsignificant after controlling for whether a language other than English was primarily spoken in the home. Analyses of kindergarten teacher-reported classroom behavior indicated that neither Black nor Hispanic children displayed less frequent ADHD-related behaviors than Whites.

CONCLUSIONS

Although they are not less likely to display ADHD-related behaviors, children who are Black or being raised in households where non-English is primarily spoken are less likely than otherwise similar White children to be diagnosed with ADHD in the US.

The effect of neighborhood and individual characteristics on pediatric critical illness

The relationship between neighborhood/individual characteristics and pediatric intensive care unit (PICU) outcomes is largely unexplored. We hypothesized that individual-level racial/ethnic minority status and neighborhood-level low socioeconomic status and minority concentration would adversely affect children's severity of illness on admission to the PICU. Retrospective analyses (1/1/2007-5/23/2011) of clinical, geographic, and demographic data were conducted at an academic, tertiary children's hospital PICU. Clinical data included age, diagnosis, insurance, race/ethnicity, Pediatric Index of Mortality 2 score on presentation to the PICU (PIM2), and mortality. Residential addresses were geocoded and linked with 2010 US Census tract data using geographic information systems geocoding techniques. Repeated measures models to predict PIM2 and mortality were constructed using three successive models with theorized covariates including the patient's race/ethnicity, the predominant neighborhood racial/ethnic group, interactions between patient race/ethnicity and neighborhood race/ethnicity, neighborhood socioeconomic status, and insurance type. Of the 5,390 children, 57.8% were Latino and 70.1% possessed government insurance. Latino children (β = 0.31; p < 0.01), especially Latino children living in a Latino ethnic enclave (β = 1.13; p < 0.05), had higher PIM2 scores compared with non-Latinos. Children with government insurance (β = 0.29; p < 0.01) had higher PIM2 scores compared to children with other payment types and median neighborhood income was inversely associated with PIM2 scores (β = -0.04 per $10,000/year of income; p < 0.05). Lower median neighborhood income, Latino ethnicity, Latino children living in a predominantly Latino neighborhood, and children possessing government insurance were associated with a higher severity of illness on PICU admission. The reasons why these factors affect critical illness severity require further exploration.

Community health workers as an integral strategy in the REACH U.S. program to eliminate health inequities

Mounting evidence indicates that community health workers (CHWs) contribute to improved behavioral and health outcomes and reductions in health disparities. We provide an overview (based on grantee reports and community action plans) that describe CHW contributions to 22 Racial and Ethnic Approaches to Community Health (REACH) programs funded by the Centers for Disease Control and Prevention from 2007 to 2012, offering additional evidence of their contributions to the effectiveness of community public health programs. We then highlight how CHWs helped deliver REACH U.S. community interventions to meet differing needs across communities to bridge the gap between health care services and community members, build community and individual capacity to plan and implement interventions addressing multiple chronic health conditions, and meet community needs in a culturally appropriate manner. The experience, skills, and success gained by CHWs participating in the REACH U.S. program have fostered important individual community-level changes geared to increase health equity. Finally, we underscore the importance of CHWs being embedded within these communities and the flexibility they offer to intervention strategies, both of which are characteristics critical to meeting needs of communities experiencing health disparities. CHWs served a vital role in facilitating and leading changes and will continue to do so.

A family-oriented psychosocial intervention reduces inflammation in low-SES African American youth

Children of low socioeconomic status (SES) are at elevated risk for health problems across the lifespan. Observational studies suggest that nurturant parenting might offset some of these health risks, but their design precludes inferences about causal direction and clinical utility. Here we ask whether a psychosocial intervention, focused improving parenting, strengthening family relationships, and building youth competencies, can reduce inflammation in low-SES, African Americans from the rural South. The trial involved 272 mothers and their 11-y-old children from rural Georgia, half of whose annual household incomes were below the federal poverty line. Families were randomly assigned to a 7-wk psychosocial intervention or to a control condition. When youth reached age 19, peripheral blood was collected to quantify six cytokines that orchestrate inflammation, the dysregulation of which contributes to many of the health problems known to pattern by SES. Youth who participated in the intervention had significantly less inflammation on all six indicators relative to controls (all P values < 0.001; effect sizes in Cohen's d units ranged from -0.69 to -0.91). Mediation analyses suggested that improved parenting was partially responsible for the intervention's benefits. Inflammation was lowest among youth who received more nurturant-involved parenting, and less harsh-inconsistent parenting, as a consequence of the intervention. These findings have theoretical implications for research on resilience to adversity and the early origins of disease. If substantiated, they may also highlight a strategy for practitioners and policymakers to use in ameliorating social and racial health disparities.

Outcomes research in childhood autoimmune diseases

This article provides an introduction to key aspects of outcomes research in pediatric rheumatology, focusing on arthritis. Patient-centered outcomes research addresses questions of interest to multiple stakeholders in order to guide the best health care decisions suited to a particular patient's circumstances and preferences. Discussion includes the importance of maintaining high-quality longitudinal patient registries and use of valid clinical and patient-reported outcome measures. Rapid, reliable translation of research on best practices into clinical care, as facilitated by quality improvement learning networks, leads to timely and meaningful improvement in patient outcomes.

The association of health literacy, social support, self-efficacy and interpersonal interactions with health care providers in low-income Latina mothers

OBJECTIVE

We explored relationships between maternal health literacy (HL), communicative self-efficacy (SE), social support (SS) and maternal perception of interactions with health care providers (HCPs).

METHODS

Using a cross-sectional, correlational design, we assessed sociodemographic characteristics, maternal HL, social support, communicative self-efficacy, and interpersonal interactions with HCPs among 124 low-income Latina mothers of young children.

RESULTS

Informal SS significantly predicted maternal SE in interactions. SE predicted maternal perception of a HCP's ability to "elicit and respond to her concerns."

DISCUSSION

Interventions to improve maternal self-efficacy in interacting with HCPs among low health literate Latina mothers may positively impact pediatric health outcomes.

Using simulation to compare 4 categories of intervention for reducing cardiovascular disease risks

The Prevention Impacts Simulation Model (PRISM) projects the multiyear impacts of 22 different interventions aimed at reducing risk of cardiovascular disease. We grouped these into 4 categories: clinical, behavioral support, health promotion and access, and taxes and regulation. We simulated impacts for the United States overall and also for a less-advantaged county with a higher death rate. Of the 4 categories of intervention, taxes and regulation reduce costs the most in the short term (through 2020) and long term (through 2040) and reduce deaths the most in the long term; they are second to clinical interventions in reducing deaths in the short term. All 4 categories combined were required to bring costs and deaths in the less-advantaged county down to the national level.

Ethnicity, socioeconomic position and severity of problems as predictors of mental health care use in 5- to 8-year-old children with problem behaviour

BACKGROUND

Empirical research on mental health care use and its determinants in young school-aged children is still scarce. In this study, we investigated the role of ethnicity, socioeconomic position (SEP) and perceived severity by both parents and teachers on mental health care use in 5- to 8-year old children with emotional and/or behavioural problems.

METHODS

Data from 1,269 children with a high score([P90) on the Strengths and Difficulties Questionnaire (SDQ) in the school year 2008–2009 were linked to psychiatric case register data over the years 2010–2011. Cox proportional hazards models were used to predict mental health care use from ethnicity, SEP and perceived severity of the child's problems.

RESULTS

During the follow-up period, 117 children with high SDQ scores (9.2 %) had used mental health care for the first time. Ethnic minority children were less likely to receive care than Dutch children (HR Moroccan/Turkish:0.26; 95 % CI 0.13-0.54, HR other ethnicity: 0.26; 95 %CI 0.12-0.58). No socioeconomic differences were found.After correction for previous care use, ethnicity and parental perceived severity, impact score as reported by teachers was significantly associated with mental healthcare use (HR 1.58; 95 % CI 1.01–2.46).

CONCLUSIONS

Ethnicity is an important predictor of mental health care use in young children. Already in the youngest school-aged children, ethnic differences in the use of mental health care are present.A distinct predictor of care use in this age group is severity of emotional and behavioural problems as perceived by teachers. Therefore, teachers may be especially helpful in the process of identifying young children who need specialist mental health care.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Outpatient utilization by infants auto-assigned to Medicaid managed care plans

To test the hypothesis that infants auto-assigned to a Medicaid managed care plan would have lower primary care and higher emergency department (ED) utilization compared to infants with a chosen plan. Retrospective cohort study. Medicaid administrative data were used to identify all children 0-3 months of age at enrollment in Michigan Medicaid managed care in 2005-2008 with 18-months of subsequent enrollment. Medicaid encounter and state immunization registry data were then acquired. Auto-assigned infants were compared versus chosen plan infants on: (1) well-child visits (WCVs); (2) immunizations; (3) acute office visits; and (4) ED visits. Chi squared and rank-sum tests and logistic and negative binomial regression were used in bivariate and multivariable analyses for dichotomous and count data, respectively. 18% of infants were auto-assigned. Auto-assigned infants were less likely to meet goal number of WCVs in 18-months of managed care enrollment (32 vs. 53%, p < 0.001) and to be up-to-date on immunizations at 12 months of age (75 vs. 85%, p < 0.001). Auto-assigned infants had fewer acute office visits (median: 4 vs. 5, p < 0.001) but were only slightly more likely to have 2 or more ED visits (51 vs. 46%, p < 0.001) in 18-months of enrollment. All results were significant in multivariable analyses. Auto-assigned infants were less likely to use preventive and acute primary care but only slightly more likely to use emergency care. Future work is needed to understand mechanisms of differences in utilization, but auto-assigned children may represent a target group for efforts to promote pediatric preventive care in Medicaid.

Nursing and health sciences workforce diversity research using PhotoVoice: a college and high school student participatory project

This participatory study used PhotoVoice and qualitative description to (a) mentor baccalaureate nursing and college students in workforce diversity research; (b) explore barriers and facilitators encountered by rural American Indian, Hispanic, and other high school students when attending college and pursuing careers in nursing or the health sciences; and (c) model a process of social action to help existing and future students. Baccalaureate nursing and graduate students participated in all stages of research, including dissemination. Five themes emerged from analysis of PhotoVoice data: (a) being afraid; (b) believing; (c) taking small steps; (d) facing fears; and (e) using support systems. Findings underscore the importance of helping students participate in efforts to increase work-force diversity through research. Increasing nursing and health sciences workforce diversity may require strategies developed within and tailored to specific cultures and communities.

Parental limited English proficiency and health outcomes for children with special health care needs: a systematic review

BACKGROUND

One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.

OBJECTIVE

To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.

DATA SOURCES

PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.

ELIGIBILITY CRITERIA

US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.

METHODS

Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.

RESULTS

From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.

CONCLUSIONS AND IMPLICATIONS

Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

Self-reported maternal parenting style and confidence and infant temperament in a multi-ethnic community: results from the Born in Bradford cohort

Ethnic minority children in the United Kingdom often experience health disadvantage. Parenting influences children's current and future health, but little is known about whether parenting behaviours and mother's perception of her infant vary by ethnicity. Using the Born in Bradford (BiB) birth cohort, which is located in an ethnically diverse and economically deprived UK city, we conducted a cross-sectional analysis of mother's self-reported parenting confidence, self-efficacy, hostility and warmth, and infant temperament at six months of age. We examined responses from women of Pakistani (N = 554) and White British (N = 439) origin. Pakistani mothers reported feeling more confident about their abilities as a parent. Significantly fewer Pakistani women adopted a hostile approach to parenting, an effect that was attenuated after adjustment for socioeconomic status and mental health. Overall, women with more self-efficacious, warm and less hostile parenting styles reported significantly fewer problems with their infant's temperaments. Of women with higher self-efficacy parenting styles, Pakistani mothers were significantly more likely than White British mothers to report more problematic infant temperaments, although absolute differences were small. It is unlikely that the ethnic variation seen in children's cognitive and behavioural outcomes in childhood is attributable to differences in parenting or infant characteristics reported at six months.