Parental English proficiency and children's health services access

Exploring Pediatric Code Status, Advance Care Planning, and Mode of Death Disparities at End of Life

CONTEXT

Children from marginalized groups are at risk for worse medical outcomes, yet little is known about their end of life experiences.

OBJECTIVE

We examine the characteristics of deceased children with a focus on race, ethnicity, and preferred language.

METHODS

We conducted a cross-sectional study of patients who died at Texas Children's Hospital from 2018 to 2019. Demographics, date of death, and final code status were extracted. Medical complexity prior to admission and mode of death were obtained from chart review.

RESULTS

We included 433 patients. Over one-third were Hispanic (39.3%) with 42.3% preferring Spanish. The majority were White (61.4%) or Black (21.0%). Most patients had significant medical complexity (52.0%) or were infants in their birth admission (29.4%). Half (52.4%) received palliative care; patients with increased medical complexity were more likely to have palliative care involved (P<0.001). There were no differences in palliative care, code status, or mode of death by race. Hispanic patients were less likely to have a full code status (OR 0.42, 95% CI: 0.25-0.73). Spanish-speaking patients were more likely to have palliative care involvement (OR 2.05, 95% CI: 1.21-3.46) and less likely full code orders (OR 0.24, 95% CI: 0.1-0.63).

CONCLUSION

Palliative care services are engaged with most children at end of life and is accessible to marginalized patient groups. Spanish-speaking patients have different code status orders and modes of death at end of life. Further studies are needed to elucidate explanatory factors for differences revealed and multicenter studies are needed to characterize more widespread experiences.

Feasibility, Acceptability, and Health Outcomes Associated With Telehealth for Children in Families With Limited English Proficiency

BACKGROUND

Telehealth use in pediatrics increased during the COVID-19 pandemic and may improve health care access. It may also exacerbate health care disparities among families with limited English proficiency (LEP).

OBJECTIVE

To systematically review the feasibility, acceptability, and/or associations between telehealth delivery and health outcomes for interventions delivered synchronously in the United States.

DATA SOURCES

PubMed, Embase, and Scopus.

STUDY ELIGIBILITY CRITERIA

Original research exploring pediatric health outcomes after telehealth delivery and studies that explored the feasibility and acceptability including surveys and qualitative studies.

PARTICIPANTS

Patients 0 to 18 years with LEP and/or pediatric caregivers with LEP.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened abstracts, conducted full-text review, extracted information using a standardized form, and assessed study quality. A third author resolved disagreements.

RESULTS

Of 1831 articles identified, 9 were included in the review. Half of the studies explored videoconferencing and the other half studied health care delivered by telephone. Feasibility studies explored telehealth for children with anxiety disorders and mobile phone support for substance abuse treatment among adolescents. Acceptability studies assessed parental medical advice-seeking behaviors and caregivers' general interest in telehealth. Health outcomes studied included follow-up of home parenteral nutrition, developmental screening, and cognitive behavioral therapy.

LIMITATIONS

The articles were heterogeneous in approach and quality.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Telehealth appears acceptable and feasible among children in families with LEP, with a limited evidence base for specific health outcomes. We provide recommendations both for the implementation of pediatric telehealth and future research.

PROSPERO REGISTRATION

CRD42020204541.

Caregiver Language Preference and Health Care Utilization Among Children With Asthma

BACKGROUND AND OBJECTIVES

Asthma is a leading cause of health care utilization in children and disproportionately affects historically marginalized populations. Yet, limited data exist on the role of caregiver language preference on asthma morbidity. The study aim was to determine whether caregiver non-English language preference (NELP) is associated with unscheduled asthma-related health care utilization in pediatric patients.

METHODS

This was a retrospective cohort study using data from a population-level, disease-specific registry of pediatric patients with asthma living in the District of Columbia (DC). Patients aged 2 to 17 years were included and the study period was 2019. The primary exposure variable was language preference: English preferred (EP) or NELP by self-identified language preference. The primary outcome was unscheduled asthma-related health care utilization including emergency department visits, hospitalizations (ICU and non-ICU), and ICU visits alone. Logistic regression was used to calculate adjusted odds ratios (aORs).

RESULTS

Of the 14 431 patients included, 8.1% had NELP (1172 patients). In analyses adjusted for age, sex, ethnicity, insurance status, diagnosis of persistent asthma, controller prescription, and encounter with a primary care provider, caregiver NELP was associated with an increased odds of having an asthma-related emergency department visit (aOR, 1.37; 95% CI, 1.08-1.74), hospitalization (aOR, 1.79; 95% CI, 1.18-2.72), and ICU visit (aOR, 4.37; 95% CI, 1.93-9.92). In the Hispanic subgroup (n = 1555), caregiver NELP was associated with an increased odds of having an asthma-related hospitalization (aOR, 1.73; 95% CI, 1.02-2.93).

CONCLUSIONS

In the population of children in the District of Columbia with asthma, caregiver NELP was associated with increased odds of asthma-related health care utilization, suggesting that caregiver language preference is a significant determinant of asthma outcomes.

Multilevel Factors Associated With Participation in Group Well-Child Care

OBJECTIVE

To identify factors associated with participation in group well-child care (GWCC), wherein families share preventive health care visits.

METHODS

We extracted electronic health record data of mother-infant dyads with infants born 2013-18 at Yale New Haven Hospital and followed at the primary care center. Using chi-square analysis and multivariate logistic regression, we examined the extent to which 1) maternal/infant characteristics and recruitment timing were associated with GWCC initiation and continued engagement and 2) initiation was associated with primary care visits.

RESULTS

Of 2046 eligible mother-infant dyads, 11.6% initiated GWCC. The odds of initiation were higher among mothers with Spanish versus English primary language (odds ratio: 2.36 [95% confidence interval: 1.52-3.66]), with 1 child versus ≥ 3 children (1.58 [1.13-2.22]), and of non-Hispanic Black versus non-Hispanic White infants (2.72 [1.39-5.32]). Initiation was lower among infants born in 2016 (0.53 [0.32-0.88]) and 2018 (0.29 [0.17-0.52]) versus 2013. Among GWCC initiators with follow-up data (n = 217), continued engagement (n = 132, 60.8%) was positively associated with maternal age of 20-29 years (2.85 [1.10-7.34]) and > 30 years (3.46 [1.15-10.43]) compared with< 20 years, and mothers with 1 child versus ≥ 3 (2.28 [1.04-4.98]). GWCC initiators, versus non-initiators, had 5.06 times higher adjusted odds of attending > 9 primary care appointments in the first 18 months (95% confidence interval: 3.74-6.85).

CONCLUSIONS

As evidence builds on health and social benefits of GWCC, recruitment efforts may gain from considering multi-level socio-economic, demographic, and cultural factors associated with GWCC participation. Higher participation among systemically marginalized groups may present unique opportunities for family-based health promotion to mitigate health inequities.

Sociodemographic and Clinical Factors Associated with Nonattendance at the Hepatology Clinic

BACKGROUND

Absenteeism from clinic appointments reduces efficiency, wastes resources, and contributes to longer wait times. There are limited data regarding factors associated with nonattendance in hepatology clinics. Identifying factors related to appointment nonattendance may help in the design of interventions for reducing absenteeism.

METHODS

We aim to identify sociodemographic, clinical, and appointment-related factors associated with absenteeism following referral to a liver clinic in a tertiary academic center located in the US Midwest. We designed a case-control study using data from electronic medical records of patients scheduled for appointments between January 2016 and December 2021. Cases were defined as patients who canceled appointments on the same day or resulting in no-shows, and controls were those who completed the referral visit. Information about patients' sociodemographic characteristics, appointment details, and etiology of liver disease were recorded. Hierarchical logistic regression was used to analyze factors related to nonattendance.

RESULTS

Of 3404 scheduled appointments, 460 (13.5%) missed visits were recorded. In the multivariable logistic regression models, hepatitis C and alcohol-associated liver disease were associated with greater odds of nonattendance [odds ratio (OR) 4.0 (95% CI 3.2-4.9), OR 2.7 (1.7-4.2), respectively] compared to those with other liver disease. Sociodemographic characteristics associated with risk of nonattendance included being Black [OR 2.6, (1.8-3.7)], Medicaid insurance or no insurance [OR 2.3 (1.7-2.9), OR 2.5 (1.6-3.7), respectively], non-English speaking [OR 1.8 (1.1-3.1)], being unmarried [OR 1.8 (1.4-2.2)], and longer wait time (> 30 days) until appointments [OR 1.8 (1.5-2.2)].

CONCLUSION

Several sociodemographic and administrative characteristics, as well as hepatitis C and alcohol-associated liver disease were associated with appointment nonattendance. Targeted future interventions may help to decrease nonattendance.

Hispanic/Latino Perspectives on Hearing Loss and Hearing Healthcare: Focus Group Results

OBJECTIVES

To better understand the hearing health learning needs of Hispanic/Latino adults by assessing hearing healthcare (HHC) knowledge, attitudes, and behaviors to inform the development of a culturally and linguistically appropriate self-management program. Through a series of focus groups with members of the target audience, this study explored knowledge about hearing loss and interventions, cultural facilitators and barriers to HHC utilization, and preferences for hearing health education and information delivery. Opinions were also received on patient education materials designed to increase self-efficacy for managing hearing loss in daily life.

DESIGN

This work was guided by a practical framework of culturally competent interventions for addressing disparities in health and healthcare, centered on structural, clinical, and organizational barriers to care. A hybrid individualistic social psychology and social constructionist approach was used to build programmatic theory related to the primary research objective. Focus group goals were to generate a combination of personal opinions and collective experiences from participants with an a priori plan to analyze data using combined content analysis/grounded theory methods. Purposive sampling was used to select 31 participants who were Spanish-speaking, identified as Hispanic/Latino, and who had normal hearing or self-reported hearing difficulties. Thirteen focus groups were conducted using Microsoft Teams, and each group was audio and video recorded for later off-line transcription, translation, and analysis. A constant comparison approach was used to systematically organize focus group data into a structured format for interpretation. Transcripts were coded independently by two investigators, and emergent themes were derived and interpreted from the coded data.

RESULTS

Major and minor themes tied to the framework for culturally competent interventions included those related to sociocultural barriers to care. Structural barriers, including inconsistent access to quality care, lack of culturally and linguistically appropriate patient education materials, appointment wait times and intake processes, and referrals to specialty care, were most frequently experienced by participants. Clinical barriers most frequently cited were a lack of culturally and linguistically congruent healthcare providers and lack of language access during healthcare visits. Other major themes included hearing loss lived experiences, family and familism, and hearing-related patient education needs and preferences.

CONCLUSIONS

Focus group results were integrated into a Spanish-language hearing loss self-management program that is currently being evaluated in a randomized controlled trial. The themes uncovered provided insight regarding the knowledge, attitudes, and beliefs about hearing loss and HHC, including hearing-related learning needs, of Hispanic/Latino adults in this sample.

U.S. national, regional, and state-specific socioeconomic factors correlate with child and adolescent ADHD diagnoses pre-COVID-19 pandemic

Attention-deficit/hyperactivity disorder (ADHD), the most diagnosed emerging neurodevelopmental disorder in children, is a growing health crisis in the United States. Due to the potential increase in ADHD severity during and post the COVID-19 pandemic, we analyzed recent national and two state-specific ADHD data distribution among U.S. children and adolescents by investigating a broad range of socioeconomic status (SES) factors. Child and adolescent ADHD diagnosis and treatment data were parent-reported via National Survey of Children's Health (NSCH). The nationwide childhood prevalence of ADHD is 8.7%, and 62.1% of diagnosed children are taking medication. Louisiana (15.7%) has the highest percentage of children diagnosed with ADHD and California (5.6%) has the lowest, followed by Nevada (5.9%). Multiple correspondence analysis (MCA, n = 51,939) examining 30 factors highlights four areas of interest at the national and state level: race/ethnicity, financial status, family structure, and neighborhood characteristics. Positive correlations between ADHD diagnosis and unsafe school, unsafe neighborhood, and economic hardship are evident nationally and statewide, while the association between a lack of ADHD diagnosis and higher urban neighborhood amenities are evident nationally, but not in two opposing outlier states-Louisiana or Nevada. National and state-specific hierarchical analyses demonstrate significant correlations between the various SES factors and ADHD outcomes. Since the national analysis does not account for the demographic heterogeneity within regions or individual states, the U.S. should rely on comprehensive, county-specific, near real-time data reporting to effectively model and mitigate the ADHD epidemic and similar national health crises.

Impact of Limited English Proficiency on Definitive Care in Pediatric Appendicitis

BACKGROUND

Limited English proficiency (LEP) is associated with decreased access to healthcare. We hypothesized that LEP children with appendicitis would experience more delays in care than EP children.

METHODS

Retrospective review of patients <18 y presenting to a tertiary pediatric hospital July 2014-July 2019 with appendicitis. LEP patients were compared to EP patients. The primary outcome was appendiceal perforation. Secondary outcomes included prior pediatrician or emergency department (ED) visits without definitive management, duration of symptoms, length of stay (LOS), initial operative or non-operative management, time from presentation to operation and return to the ED within 30 d. Multivariable regression was performed to evaluate LEP as a predictor of study outcomes.

RESULTS

A total of 893 patients with appendicitis were identified, 15.6% (n = 140) had LEP. On multivariate regression LEP was not a significant predictor of appendiceal perforation (AOR 1.20, 95% CI 0.79, 1.80, P = 0.390). LEP was a significant predictor of a prior ED or pediatrician visit without definitive management (AOR 2.05, 95 % CI 1.05, 3.98, P= 0.034) and longer LOS (Coefficient 1.01, 95% CI 0.41, 1.61, P= 0.001). LEP was associated with a minimal increase in duration of pain prior to presentation that was not clinically significant and was not associated with initial operative or non-operative management or a significantly longer time between presentation and operation.

CONCLUSIONS

LEP children did not experience higher rates of appendiceal perforation at our institution, but were more frequently initially evaluated by a pediatrician or at an ED and discharged without definitive management and had longer LOS.

The determinants of immigrant health insurance in the United States: Understanding the role of health care in origin societies

We examine how immigrants' health insurance in the United States is shaped by institutional traits of the health care systems in their origin societies. Conditional on a wide range of individual, country-of-origin, state-level, and temporal controls, we find the affordability of health care back home helps explain immigrants' US health coverage. Specifically, low- and middle-income migrants from countries with less affordable health care are more likely to get private insurance once in the United States and, correspondingly, less likely to have public coverage, relative to migrants from countries with more affordable care. The relationship conforms to multiple hypotheses. As predicted by the institutional beliefs hypothesis, migrants from countries with less affordable care might anticipate equally expensive health services in the United States and, in turn, insure themselves against high medical bills. Likewise, as predicted by the endogenous preferences hypothesis, migrants from countries with less affordable care might be accustomed to paying more for health care and, in turn, be less reluctant to pay for private health insurance. Overall, the findings underscore the relevance of migrants' past health care experiences in their origin societies in informing their health insurance in the United States even years after migration.

Cross-Cultural Adaptation of Hearing Loss Self-Management Patient Education Materials: Development of the Caja de Instrumentos de Pérdida Auditiva

Purpose The lack of culturally and linguistically appropriate interventions contributes to unsatisfactory hearing health care service delivery and outcomes for Spanish-speaking persons from Hispanic/Latino background. To address this issue, our objective was to cross-culturally adapt a "Hearing Loss Toolkit for Self-Management" for use with Spanish-speaking adults seen in a clinical setting. In this clinical focus article, we describe a process for translation and cross-cultural adaptation of patient education materials based on current best practices guidelines. Method We utilized guidelines from the International Society for Pharmoeconomics Outcomes Research Task Force for Translation and Cultural Adaptation, the World Health Organization, and the International Collegium of Rehabilitative Audiology to complete a comprehensive, systematic, cross-cultural adaptation process of the source materials. The adaptation stages included forward translation and reconciliation, back translation and review, field testing with representative end users from the target population, and finalization. Results We successfully cross-culturally adapted the source materials following best practice guidelines. The Spanish-language adaptation was deemed understandable, actionable, aesthetically pleasing, and culturally appropriate by a group of native Spanish speakers. Conclusions There is an unmet need for the development of hearing loss self-management materials that incorporate cultural and linguistic competence with best health literacy practices. High-quality cross-cultural adaptations that consider the intersection of culture, language, and health literacy are a positive step toward reducing barriers to hearing health care related to language access for U.S. Hispanic/Latino adults with hearing loss.

A Community-Based Organization Model to Promote Latinx Immigrant Mental Health Through Advocacy Skills and Universal Parenting Supports

The unique mental health context of children in Latinx immigrant families calls for innovative community-based intervention strategies. We use an ecological public health approach to highlight the importance of community-based organization (CBO) settings, the critical role of community-based paraprofessionals (i.e., non-clinicians, near-peers) and capacity-building, and the expansion of mental health promotion strategies to include realistic, day-to-day supports for Latinx immigrant parents and families. This realigns mental health with the goals and mission of trusted spaces, like CBOs, that can offer more equitable and non-stigmatized access for Latinx immigrant families. We draw upon two strength-based and empowerment-focused interventions that utilize community-based workforces to promote positive parenting skills (Partners Achieving Student Success-PASS; Mehta et al., 2019) and self-advocacy skills (Community Advocacy Project-CAP; Sullivan & Bybee, 1999) to provide the conceptual framework for Family Mental Health Advocacy (FMHA). FMHA aligns mental health promotion with the advocacy mission of CBOs, engages CBO staff with feasible mental health "messages," and empowers immigrant parents as critical change agents in the lives of their children. We acknowledge the challenges associated with implementing mental health promotion strategies and providing workforce support, as well as the importance of local and national policy influences.

Asthma-Related Emergency Department Visits Among Low-Income Families With Young Children by Race/Ethnicity and Primary Language

OBJECTIVE

The aim of this study was to examine the existence of racial/ethnic and language disparities in asthma-related emergency department (ED) initial and return visits among young children in low-income families in California.

METHODS

Children younger than 6 years with at least 1 asthma-related ED visit recorded in the California Office of Statewide Health Planning and Development data set between January 1, 2009, and December 31, 2013, and on Medicaid (Medi-Cal) were assessed. Primary outcomes were hospitalization at the first asthma-related ED visit and a return asthma-related ED visit within 12 months. Data were analyzed using multivariate logistic regression.

RESULTS

Among 47,657 children, approximately 55% were Hispanic, 20% were black, and 2.7% were Asian/Pacific Islander. For non-English-speaking families, 82% were Hispanic. Among English-speaking families, blacks were less likely to be hospitalized at the first ED visit (odds ratio [OR], 0.787; 95% confidence interval [CI], 0.715-0.866) but more likely to return to the ED (OR, 1.291; 95% CI, 1.205-1.383) compared with whites. Conversely, Asian/Pacific Islanders whose primary language was English were more likely to be hospitalized (OR, 2.150; 95% CI, 1.827-2.530) compared with whites. Among families whose primary language was not English, Hispanic and Asian/Pacific Islanders are more likely to be hospitalized at the first ED visit and all groups are less likely to return to the ED compared with English-speaking whites.

CONCLUSIONS

The findings suggest that racial/ethnic and language disparities exist in eventual asthma-related hospitalizations and repeat ED visits. Continued research is needed to understand the existence of these differences and to inform future comprehensive and linguistically appropriate asthma interventions for children in low-income families.

Health service utilisation and unmet healthcare needs of Australian children from immigrant families: A population-based cohort study

Compared with most other Organization for Economic Co-operation and Development (OECD) countries, information about the patterns of health service use for children from immigrant families in Australia is currently limited, and internationally, data on unmet healthcare needs are scarce. This study aims to examine the distribution of health service utilisation and unmet healthcare needs for immigrant children aged 10-11 years in Australia. We drew on data from the Longitudinal Study of Australian Children Birth (B; n = 5,107) and Kindergarten (K; n = 4,983) cohorts. The exposure was family immigration background collected at 0-1 (B-cohort) and 4-5 (K-cohort) years. Outcomes were parent-reported child health service use and unmet healthcare needs (defined as the difference between services needed and services received) at 10-11 years. Logistic regression analyses were used to examine associations between family immigration background and health service use/unmet healthcare needs, adjusting for potential confounders. Results showed that one-third of Australian children (B-cohort: 29.0%; K-cohort: 33.4%) came from immigrant families. There were similar patterns of health service use and unmet healthcare needs between children from English-speaking immigrant and Australian-born families. However, children from non-English-speaking immigrant families used fewer health services, including paediatric, dental, mental health and emergency ward services. There was a disparity between the services used when considering children's health needs, particularly for paediatric specialist services (B-cohort: OR = 2.43, 95% CI 1.11-5.31; K-cohort: OR = 2.72, 95% CI 1.32-5.58). Findings indicate that Australian children from non-English-speaking immigrant families experience more unmet healthcare needs and face more barriers in accessing health services. Further effort is needed to ensure that the healthcare system meets the needs of all families.

High Level of Food Insecurity among Families with Children Seeking Routine Care at Federally Qualified Health Centers during the Coronavirus Disease 2019 Pandemic

Objective

To assess food insecurity during pediatric visits to federally qualified health centers (FQHCs) during the coronavirus disease-19 pandemic.

Study design

Interviews using the validated American Academy of Pediatrics 2-question food insecurity screen were performed with 200 consecutive families presenting for pediatric care to 2 FQHC in Central Texas from April 14 to May 20, 2020, during the initial phase of the pandemic in Texas. Brief qualitative interviews were conducted to determine whether families found a worsening of food insecurity during the pandemic.

Results

Overall, 47% of families had a positive food insecurity screen. More than 90% of these were worrying about food running out and about 60% were positive for the question related to food not lasting. Among families with food insecurity, 94% indicated this had begun or worsened during the pandemic. Of the 115 families volunteering information about employment, 46% reported job loss during this time period. Both ethnicity (P < .001) and Special Supplementation Nutrition Program for Women, Infants and Children (WIC) participation (P = .03) were associated with greater levels of food insecurity. Among primarily Spanish-speaking families participating in the WIC program, 64% reported food insecurity.

Conclusions

Approximately one-half of families receiving routine pediatric care at a FQHC during the coronavirus disease-19 pandemic reported food insecurity and this was associated with loss of jobs during the pandemic. Participation in the WIC program was not protective against food insecurity. Increased frequency of food insecurity was detected in Hispanic and Spanish-speaking families. Screening of families at an FQHC should be strongly considered as a part of routine pediatric care. Knowledge of community resources is important for providers to share with patients. (J Pediatr: X 2020;4:100044).

Trial Registration

ClinicalTrials.gov: NCT04378595

Leaving Paper Behind: Improving Healthcare Navigation by Latino Immigrant Parents Through Video-Based Education

System barriers to effective healthcare engagement and navigation contribute to healthcare disparities among Latino children with immigrant parents in the US. We evaluated a nine-minute educational video supporting healthcare navigation and engagement skills of Spanish-speaking Latino parents of infants. Participants viewed the video at their child's 2-month well-visit, completed a pre-and post-video knowledge evaluation, and answered open-ended questions on video style. A paired t test was used to examine differences in knowledge and open-ended responses were coded using an iterative, consensus-based process. Of the 79 participants, 63.3% had an education level below high school diploma/GED and 84.8% were at risk for limited health literacy. There was a significant gain in healthcare navigation and engagement knowledge after watching the video (p < 0.001). Parents expressed that the video was interesting and provided useful information. Parents valued the knowledge gained and preferred videos over written materials for receiving culturally and linguistically tailored health education.

Neonatal Intensive Care Unit discharge preparedness among families with limited english proficiency

OBJECTIVE

We compared the Neonatal Intensive Care Unit discharge preparedness of families with and without Limited English Proficiency (LEP).

STUDY DESIGN

We performed a retrospective analysis of discharged families. Each family's discharge preparation was self-assessed on the day of discharge, and the discharging nurse assessed the family's overall emotional and technical discharge preparedness all on 9-point Likert scales. Families were considered not prepared for discharge if they rated themselves or the nurse rated their preparedness as <7 on the Likert scale.

RESULTS

Among 1307 discharged families, 90 had LEP. The odds of being prepared for discharge were the same for both groups (aOR = 0.62, 95% CI: 0.27-1.41; p = 0.258). In multivariable analyses, families with LEP were less likely to be prepared with technical baby care skills (aOR = 0.32, 95% CI: 0.13-0.81).

CONCLUSION

Families with LEP are at higher risk and may require special attention when preparing for NICU discharge.

Health Care Access Barriers Bring Children to Emergency Rooms More Frequently: A Representative Survey

Children may visit the emergency department (ED) regularly in part because they and their caregivers may be experiencing barriers to appropriate and timely pediatric care. However, assessing the wide range of potential barriers to access to care that children and their caregivers may experience is often a challenge. The objective of this study was to assess the barriers to pediatric health care reported by caregivers and to examine the association between those reported barriers to care with the frequency of children's ED visits in the past 12 months. Assessment of ED utilization and access to care barriers was made through a telephone interview survey conducted as part of a broader Community Health Needs Assessment in 2015. A weighted community sample of adult caregivers (N = 1057) of children between the ages of 0-17 residing in Miami-Dade, Broward, and Palm Beach counties, Florida were contacted. This study found that multiple ED visits (≥2 vs. 0) in the past 12 months by a child were most strongly associated with access to care barriers attributed to language and culture (relative risk [RR] = 2.51), trouble finding a doctor (RR = 1.86), scheduling an appointment (RR = 1.68), and transportation access (RR = 1.73). These findings suggest that access to care barriers experienced by households may exacerbate the risk of a child experiencing repeated visits to the ED in a year. Findings are discussed further in the context of actionable population health management strategies to reduce risk of frequent ED utilization by children.

Nativity as a Determinant of Health Disparities Among Children

Nativity is not often considered in the study of health disparities. We conducted a cross-sectional, parent-reported survey of demographics, socioeconomic characteristics, healthcare access, and health conditions in New York City schoolchildren (n = 9029). US-born children with US-born parents (US/US) had higher socioeconomic status, better access to healthcare, and reported higher rates of disease diagnoses compared to US-born children with immigrant parents and to immigrant children. Dental cavities were the only condition in which US/US children reported lower prevalence. US/US children had the best healthcare access, most favorable parent-reported health status and highest rate of satisfaction with healthcare. The magnitude of racial/ethnic disparities varied based on nativity of the children being compared. Factors such as the healthy immigrant effect and differential diagnosis rates may explain the results. In conclusion, nativity influences disease burdens and should be considered in health disparities studies.

Homecare and Healthcare Utilization Errors Post-Neonatal Intensive Care Unit Discharge

Background:

High-risk infants transitioning from the neonatal intensive care unit (NICU) to home represent a vulnerable population, given their complex care requirements. Little is known about errors during this period.

Purpose:

Identify and describe homecare and healthcare utilization errors in high-risk infants following NICU discharge.

Methods:

This was a prospective observational cohort study of homecare (feeding, medication, and equipment) and healthcare utilization (appointment) errors in infants discharged from a regional NICU between 2011 and 2015. Chi-square test and Wilcoxon rank-sum test were used to compare infant and maternal demographics between infants with and without errors.

Results:

A total of 363 errors were identified in 241 infants during 635 home visits. The median number of visits was 2. No significance was found between infant and maternal demographics in those with or without errors.

Implications of Practice:

High-risk infants have complex care needs and can benefit from regular follow-up services. Home visits provide an opportunity to identify, intervene, and resolve homecare and healthcare utilization errors.

Implications of Research:

Further research is needed to evaluate the prevalence and cause of homecare errors in high-risk infants and how healthcare resources and infant health outcomes are affected by those errors. Preventive measures and mitigating interventions that best address homecare errors require further development and subsequent description.

Ventanillas de Salud: A Collaborative and Binational Health Access and Preventive Care Program

While individuals of Mexican origin are the largest immigrant group living in the U.S., this population is also the highest uninsured. Health disparities related to access to health care, among other social determinants, continue to be a challenge for this population. The government of Mexico, in an effort to address these disparities and improve the quality of life of citizens living abroad, has partnered with governmental and non-governmental health-care organizations in the U.S. by developing and implementing an initiative known as Ventanillas de Salud—Health Windows—(VDS). The VDS is located throughout the Mexican Consular network and aim to increase access to health care and health literacy, provide health screenings, and promote healthy lifestyle choices among low-income and immigrant Mexican populations in the U.S.

The Effect of Limited English Proficiency on Pediatric Hospital Readmissions

BACKGROUND

The relationship between limited English proficiency (LEP) and worse pediatric health outcomes is well documented.

OBJECTIVES

To determine the relationship between LEP status and pediatric hospital readmissions.

METHODS

We performed a retrospective cohort analysis of children ≤ 18 years old admitted to a tertiary children's hospital from 2008 to 2014. The main exposure was LEP status. Independent variables included sex, age, race/ethnicity, insurance, median household income, surgical/medical status, severity of illness (SOI), the presence of a complex chronic condition, and length of stay. Primary outcome measures were 7- and 30-day readmission.

RESULTS

From 67 473 encounters, 7- and 30-day readmission rates were 3.9% and 8.2%, respectively. LEP patients were more likely to be younger, poorer, and Hispanic; have lower SOI; and government-subsidized insurance. Adjusted odds for 7- or 30-day readmission for LEP versus English-proficient (EP) patients were 1.00 (P = .99) and 0.97 (P = .60), respectively. Hispanic ethnicity (adjusted odds ratio [aOR]: 1.26 [P = .002] and 1.14 [P = .02]), greater SOI (aOR: 1.04 [P < .001] and 1.05 [P < .001]), and the presence of a complex chronic condition (aOR: 2.31 [P < .001] and 3.03 [P < .001]) were associated with increased odds of 7- and 30-day readmission, respectively. White LEP patients had increased odds of 7- and 30-day readmission compared with white EP patients (aOR: 1.46 [P = .006] and 1.32 [P = .007]) and the poorest LEP patients had increased odds of 7- and 30-day readmission compared with the poorest EP patients (aOR: 1.77 [P = .04] and 2.00 [P < .001]).

CONCLUSIONS

This is the first large study evaluating the relationship between LEP and pediatric hospital readmission. There was no increased risk of readmission in LEP patients compared with EP patients.

Legal Status and Health Care: Mexican-Origin Children in California, 2001-2014

Using restricted data from the 2001-2014 California Health Interview Surveys, this research illuminates the role of legal status in health care among Mexican-origin children. The first objective is to provide a population-level overview of trends in health care access and utilization, along with the legal statuses of parents and children. The second objective is to examine the nature of associations between children's health care and legal status over time. We identify specific status-based distinctions that matter and investigate how their importance is changing. Despite the continuing significance of child nativity for health care, the descriptive analysis shows that the proportion of Mexican-origin children who are foreign born is declining. This trend suggests a potentially greater role of parental legal status in children's health care. Logistic regression analyses demonstrate that the importance of parental legal status varies with the health care indicator examined and the inclusion of child nativity in models. Moreover, variation in some aspects of children's health care coalesced more around parents' citizenship than documentation status in the past. With one exception, the salience of such distinctions has dissipated over time.

Health Care Engagement of Limited English Proficient Latino Families: Lessons Learned from Advisory Board Development

BACKGROUND

Specific information on the development and evaluation of patient/family engagement in health care improvement for populations with limited English proficiency (LEP) is lacking.

OBJECTIVES

We sought to provide information for use by other health care organizations aiming to engage LEP populations through advisory groups.

METHODS

Informed by community-based research principles, we formed a family advisory board of LEP Latino families and conducted a multimodal evaluation of initial implementation and partnership development.

RESULTS

The board met process measures goals for sustained engagement of LEP families and for establishing a group structure and process. Board outcomes included contributions to clinic educational materials and initiation of a project to increase the child friendliness of the physical space. Mothers on the board reported satisfaction with their participation.

CONCLUSIONS

We successfully sustained engagement of LEP Latino families in health care improvement using an advisory board. To promote patient-centered care and address health care disparities, LEP populations should be included in patient engagement programs.

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.

More than interpreters needed: the specialized care of the immigrant pregnant patient

The immigrant pregnant woman faces unique challenges. This article provides an overview of these challenges and interventions to maximize health outcomes for the immigrant pregnant woman. A patient's immigrant status may impact her social stability and access to health care. Lack of familiarity with western health care, health financing, and the English language can create significant barriers. In addition, providers must remember to evaluate the immigrant pregnant woman for underlying health conditions that may be present including infectious diseases endemic to their country of origin and chronic diseases or cervical center as yet unidentified because of lack of previous health care screening. Female genital modification found in some immigrant populations can be associated with poorer obstetric outcomes and should be documented and addressed. Finally, some immigrant populations have a high incidence of past severe trauma and need additional psychiatric evaluation and support.

Parental immigration status is associated with children's health care utilization: findings from the 2003 new immigrant survey of US legal permanent residents

Our objective was to examine the association between parental immigration status and child health and health care utilization. Using data from a national sample of immigrant adults who had recently become legal permanent residents (LPR), children (n = 2,170) were categorized according to their parents' immigration status prior to LPR: legalized, mixed-status, refugee, temporary resident, or undocumented. Logistic regression with generalized estimating equations was used to compare child health and health care utilization by parental immigration status over the prior 12 months. Nearly all children in the sample were reported to be in good to excellent health. Children whose parents had been undocumented were least likely to have had an illness that was reported to have required medical attention (5.4 %). Children whose parents had been either undocumented or temporary residents were most likely to have a delayed preventive annual exam (18.2 and 18.7 %, respectively). Delayed dental care was most common among children whose parents had come to the US as refugees (29.1 %). Differences in the preventive annual exam remained significant after adjusting for socioeconomic characteristics. Parental immigration status before LPR was not associated with large differences in reported child health status. Parental immigration status before LPR was associated with the use of preventive annual exams and dental services. However, no group of children was consistently disadvantaged with respect to all measures.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children

OBJECTIVE

To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain.

STUDY DESIGN

We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models.

RESULTS

Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95).

CONCLUSION

Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Undocumented Immigrants and Access to Health Care: Making a Case for Policy Reform

The growth in undocumented immigration in the United States has garnered increasing interest in the arenas of immigration and health care policy reform. Undocumented immigrants are restricted from accessing public health and social service as a result of their immigration status. The Patient Protection and Affordability Care Act restricts undocumented immigrants from participating in state exchange insurance market places, further limiting them from accessing equitable health care services. This commentary calls for comprehensive policy reform that expands access to health care for undocumented immigrants based on an analysis of immigrant health policies and their impact on health care expenditures, public health, and the role of health care providers. The intersectional nature of immigration and health care policy emphasizes the need for nurse policymakers to advocate for comprehensive policy reform aimed at improving the health and well-being of immigrants and the nation as a whole.

Language and immigrant status effects on disparities in Hispanic children's health status and access to health care

The objective of this study is to estimate Hispanic/non-Hispanic (nH)-white health disparities and assess the extent to which disparities can be explained by immigrant status and household primary language. The 2007 National Survey of Children's Health was funded by the Maternal and Child Health Bureau, and conducted by Centers for Disease Control and Prevention's National Center for Health Statistics as a module of the State and Local Area Integrated Telephone Survey. We calculated disparities for various health indicators between Hispanic and nH-white children, and used logistic regression to adjust them for socio-economic and demographic characteristics, primary language spoken in the household, and the child's immigrant status. Controlling for language and immigrant status greatly reduces health disparities, although it does not completely eliminate all disparities showing poorer outcomes for Hispanic children. English-speaking and nonimmigrant Hispanic children are more similar to nH-white children than are Hispanic children in non-English speaking households or immigrant children. Hispanic/nH-white health disparities among children are largely driven by that portion of the Hispanic population that is either newly-arrived to this country or does not speak primarily English in the household.

Changes in language services use by US pediatricians

BACKGROUND AND OBJECTIVES

Access to appropriate language services is critical for ensuring patient safety and reducing the impact of language barriers. This study compared language services use by US pediatricians in 2004 and 2010 and examined variation in use in 2010 by pediatrician, practice, and state characteristics.

METHODS

We used data from 2 national surveys of pediatricians (2004: n = 698; 2010: n = 683). Analysis was limited to postresidency pediatricians with patients with limited English proficiency (LEP). Pediatricians reported use of ≥ 1 communication methods with LEP patients: bilingual family member, staff, physician, formal interpreter (professional, telephone), and primary-language written materials. Bivariate analyses examined 2004 to 2010 changes in methods used, and 2010 use by characteristics of pediatricians (age, sex, ethnicity), practices (type, location, patient demographics), and states (LEP population, Latino population growth, Medicaid/Children's Health Insurance Program language services reimbursement). Multivariate logistic regression was performed to determine adjusted odds of use of each method.

RESULTS

Most pediatricians reported using family members to communicate with LEP patients and families, but there was a decrease from 2004 to 2010 (69.6%, 57.1%, P < .01). A higher percentage of pediatricians reported formal interpreter use (professional and/or telephone) in 2010 (55.8%) than in 2004 (49.7%, P < .05); the increase was primarily attributable to increased telephone interpreter use (28.2%, 37.8%, P < .01). Pediatricians in states with reimbursement had twice the odds of formal interpreter use versus those in nonreimbursing states (odds ratio 2.34; 95% confidence interval 1.24-4.40).

CONCLUSIONS

US pediatricians' use of appropriate language services has only modestly improved since 2004. Expanding language services reimbursement may increase formal interpreter use.

The voices of limited English proficiency Latina mothers on pediatric primary care: lessons for the medical home

The objective of this study is to inform medical home implementation in practices serving limited English proficiency Latino families by exploring limited English proficiency Latina mothers' experiences with, and expectations for, pediatric primary care. In partnership with a federally-qualified community health center in an urban Latino neighborhood, we conducted semi-structured interviews with 38 low-income Latina mothers. Eligible participants identified a pediatric primary care provider for their child and had at least one child 3 years old or younger, to increase the probability of frequent recent interactions with health care providers. Interview transcripts were coded and analyzed through an iterative and collaborative process to identify participants' satisfaction with and expectations for pediatric primary care. About half of the mothers interviewed were satisfied with their primary care experiences. Mothers suggested many ways to improve the quality of pediatric primary care for their children to better meet the needs of their families. These included: encouraging providers to invest more in their relationship with families, providing reliable same-day sick care, expanding hours, improving access to language services, and improving care coordination services. Limited English proficiency Latina mothers expect high-quality pediatric primary care consistent with the medical home model. Current efforts to improve primary care quality through application of the medical home model are thus relevant to this population, but should focus on the parent-provider relationship and timely access to care. Promoting this model among practices that serve limited English proficiency Latino families could improve engagement and satisfaction with primary care.

Selected Health Status Measures of Children from US Immigrant Families

Using the 2007 National Survey of Children's Health (N = 91,532), we studied the relationship between the joint effects of immigrant family type (foreign-born children, US-born children/one foreign-born parent, US-born children/both foreign-born parents, and US-born children/US-born parents) and race/ethnicity on various health measures (parent-reported physical and dental health, obesity/overweight, breast-feeding, school absence, injury, and chronic condition). We used weighted logistic regression to examine the independent effects of the 12-level joint variable on various health status measures while controlling for confounding factors. Overall, nearly one-third of families with both foreign-born parents were poor, and one-quarter of the parents in these households did not complete high school. Compared with non-Hispanic White US-born children, multivariable analyses indicate that all Hispanic children have higher odds of obesity, poor physical and dental health, with Hispanic foreign-born children 7 times as likely to report poor/fair physical health. Most children of immigrant parents were more likely to have been breast-fed and less likely to miss school more than 11 days. Child age and household poverty status were independently associated with most of the health status measures. Combined race/ethnicity and immigrant family type categories have heterogeneous associations with each health outcome measure examined. Culturally competent interventions and policies should be developed to serve these expanding communities.

Comparison of primary physician patterns of and attitudes on emergency department use

OBJECTIVE

This study aimed to compare physician viewpoints and clinic patterns between primary care providers (PCPs) with high patient emergency department (ED) use (HU) and PCPs with low patient ED use (LU).

METHODS

We conducted a mixed methods descriptive study of quantitative and qualitative data of 22 practices. We compared admission rates, American Academy of Pediatrics guideline adherence, efficiency, medical complexity, and patient satisfaction. Primary care provider interviews regarding ED use practices and perspectives were coded and inductively analyzed using Atlas 6.0 for themes.

RESULTS

Compared with LU, the HU group had a higher admission rate (92 vs 41 admissions per 1000 members, P = 0.005), lower scores in adherence to American Academy of Pediatrics guidelines, and higher scores in satisfaction overall. There were no significant differences in efficiency, medical complexity, PCP communications, timeliness for appointment, satisfaction with after-hour care or likelihood of PCP referral. All PCPs described the EDs' purpose as for things they "cannot handle." The LU group was more likely to identify the ED for emergencies, whereas the HU group had a broader, more ambiguous definition of what they "cannot handle," with parental anxiety identified as a significant factor. In addition, the LU group recognized the need for more parental education about ED use.

CONCLUSIONS

Primary care providers with low patient ED use were more likely to describe the EDs' purpose as being for emergencies and to recognize a need for more parental education about the use of the ED. All physicians struggled with reassuring parents.

Autism spectrum disorders and developmental disabilities in children from immigrant families in the United States

OBJECTIVES

Recent census data show that nearly one-quarter of US children have at least 1 immigrant parent; moreover, there has been a dramatic increase in children diagnosed with autism spectrum disorders (ASDs) and select developmental disabilities (DDs). However, little is known about access to medical home and adequacy of insurance coverage for children with ASDs and select DDs from immigrant families.

METHODS

By using the 2007 National Survey of Children's Health, we compared children with ASDs and select DDs from immigrant (n = 413, foreign born or reside with at least 1 immigrant parent) and nonimmigrant (n = 5411) families on various measures of medical home and insurance coverage. We used weighted logistic regression to examine the association between immigrant family and selected outcome measures while controlling for confounding factors.

RESULTS

Compared with nonimmigrant families, children with ASD and select DD from immigrant families were more than twice as likely to lack usual source of care and report physicians not spending enough time with family. Furthermore, multivariable analyses indicate that insurance coverage is an important factor in mitigating health care barriers for immigrant families.

CONCLUSIONS

The study demonstrates important areas of deficits in the health care experiences of children with ASD and select DD from immigrant households. Public policy implications include increasing access to existing insurance programs, augmenting public awareness resources for ASD and select DD, and offering assistance to immigrant families that are struggling with the medical needs of their children.

High parenting aggravation among US immigrant families

OBJECTIVES

We examined the association between the joint effects of children's immigrant family type and race/ethnicity on parenting aggravation.

METHODS

We analyzed data on a nationally representative sample of 101 032 children aged birth through 17 years from the 2003 National Survey of Children's Health.

RESULTS

Analysis of the Aggravation in Parenting Scale showed that 26% of foreign-born parents with foreign-born children were highly aggravated, followed by 22% of foreign-born parents with US-born children and 11% of US-born parents. Multivariable analyses indicated that all minority parents experienced high parenting aggravation compared with non-Hispanic White US-born parents; the odds of reporting parenting aggravation were 5 times higher for Hispanic foreign-born parents. All foreign-born parents, regardless of race/ethnicity, reported significantly elevated parenting aggravation. Parents of adolescents, children with special health care needs, and nontraditional and lower-income households were also more likely to report high parenting aggravation.

CONCLUSIONS

Our findings clearly document significantly elevated levels of parenting aggravation among immigrant and minority families. Public health programs and clinicians should target referrals and interventions for these families to avoid potential health problems for both children and their families.

Unmet need and problems accessing core health care services for children with autism spectrum disorder

To investigate the health care experiences of children with autism spectrum disorder, whether they have unmet needs, and if so, what types, and problems they encounter accessing needed care. We address these issues by identifying four core health care services and access problems related to provider and system characteristics. Using data from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN) we compared children with autism spectrum disorder with children with special health care needs with other emotional, developmental or behavioral problems (excluding autism spectrum disorder) and with other children with special health care needs. We used weighted logistic regression to examine differences in parent reports of unmet needs for the three different health condition groups. Overall unmet need for each service type among CSHCN ranged from 2.5% for routine preventive care to 15% for mental health services. After controlling for predisposing, enabling and need factors, some differences across health condition groups remained. Families of children with autism spectrum disorder were in fact significantly more at risk for having unmet specialty and therapy care needs. Additionally, families of children with autism spectrum disorder were more likely to report provider lack of skills to treat the child as a barrier in obtaining therapy and mental health services. Disparities in unmet needs for children with autism suggest that organizational features of managed care programs and provider characteristics pose barriers to accessing care.

Understanding the Gap in Primary Care Access and Use Between Teens and Younger Children

Primary health care use among teenagers falls short of clinical recommendations and consistently lags behind that of younger children. Using the Medical Expenditure Panel Survey, the authors explore three explanations for this age-related gap: family composition, parental awareness of children’s health care needs, and the relative role of predisposing, enabling, and need-based factors for teens and younger children. Teenagers are 64% more likely to have no usual source of care and 25% more likely to have had no health care visit in the prior year relative to younger children. The gap narrows in families with children from both age-groups and among children with special health care needs. The largest disparity in primary care access exists between teens in families with no younger sibling(s) and younger children in families with no teen(s). A resolution to the age-related access gap will likely require understanding of, and intervention into, family-level determinants of poor access.

Health care of Latino children with autism and other developmental disabilities: quality of provider interaction mediates utilization

This study examines access to, utilization of, and quality of health care for Latino children with autism and other developmental disabilities. We analyze data from the National Survey of Children with Special Health Care Needs (N  =  4,414 children with autism and other developmental disabilities). Compared with White children, Latino children with autism and other developmental disabilities had a consistent pattern of worse health care access, utilization, and quality. We then test mediation models to determine if health care quality mediates the relationship between ethnicity and health care utilization disparities. Three of four quality indicators (provider does not spend enough time with child, provider is not culturally sensitive, and provider does not make parent feel like a partner) were significant mediators. These analyses suggest that interventions targeted at improving providers' cultural sensitivity and behavior during the clinical encounter may reduce disparities in the health care utilization of Latino children with autism and other developmental disabilities.

Effect of acculturation and distance from cardiac center on congenital heart disease mortality

BACKGROUND AND OBJECTIVE

Despite improvements in congenital heart disease (CHD) survival over the past 4 decades, ethnic disparities persist. Several studies have shown higher postoperative CHD adjusted mortality in black and Hispanic children. Others noted that non-English-speaking language at home was associated with appointment noncompliance, which the parents attributed to misunderstanding and living too far from a health center. The purpose of this study was to determine the effect of home distance to a cardiac center, or having a Latin American-born parent, on first-year mortality in infants with severe CHD.

METHODS

Infants with severe CHD, having an estimated first-year mortality >25%, born 1996-2003, were identified from the Texas Birth Defects Registry and linked to state and national vital records. We examined the effects of defect type; birth weight; gestational age; extracardiac anomalies; infant gender; maternal race/ethnicity, marital status, and education; residence in a Texas county bordering Mexico; home distance to cardiac center; and parental birth country on first-year survival.

RESULTS

Overall first-year survival was 59.9%, and no race/ethnic differences were noted; however, survival was significantly (P < .05) lower for Hispanic infants with hypoplastic left heart syndrome. Neither home distance to a cardiac center nor parental birth country was related to first-year survival; however, survival was noted to be lower in Texas counties bordering Mexico, counties that have high rates of poverty.

CONCLUSIONS

Further studies are needed to determine if these disparities in survival of infants with severe CHD are attributable to delays in referral to a cardiac center.

Medical home disparities for Latino children by parental language of interview

Examination of Latino children in aggregate ignores important subgroup differences due to the parents' English language ability. Previous reports of the pediatric medical home have not stratified Latino children by parental language differences to compare the two groups directly. We analyzed the 2007 National Survey of Children's Health to determine medical home prevalence among Latino children, stratified by language of parental interview. Most Latino children with a Spanish-language parental interview had a usual source of care, but only one-quarter had a medical home. Striking medical home disparities persisted for Latino children with a Spanish-language interview, even after adjustment for potential confounders. Lack of a medical home was associated with disparities in the quality of care, more so than access disparities. Addressing health care disparities for Latino children requires particular attention to the unique needs of Latino children with parents who may experience language barriers during health care encounters.

Factors associated with intensiveness of use of child preventive health services in Taiwan: a comparative study between cross-cultural immigrant families and native-born families

OBJECTIVES

To compare intensiveness of use of child preventive health services (CPHS) between cross-cultural immigrant families and native-born families in Taiwan and to explore factors associated with differences in intensiveness of CPHS use.

DESIGN

Cross-cultural immigrant families were defined as families where the mother was an immigrant from another southeast Asian country. In native-born families, both parents were Taiwanese-born. Data were collected from 318 immigrant mothers and 340 native-born mothers of children aged 7 years or younger in a cross-sectional survey in central Taiwan. A social determinants framework of health inequities was constructed, and ordinal logistic regression models were used to examine the effect of four domains of intermediary determinants on the relationship between family type and underuse of CPHS: CPHS-related factors, medical-related factors, maternal acculturation factors, and sociodemographic/socioeconomic characteristics.

RESULTS

Cross-cultural immigrant families were less likely to intensively use CPHS than native-born families. This difference appeared to be mediated by the greater likelihood of having an older child or a lower educated father in cross-cultural families.

CONCLUSION

Findings of this study highlight the importance of promoting health behaviors and combating health inequities and social inequalities for cross-cultural immigrant families in Taiwan from a sociodemographic/socioeconomic and political context.

Effects of length of stay and language proficiency on health care experiences among immigrants in Canada and the United States

This study sought to examine the influence of length of stay and language proficiency on immigrants' access to and utilization of care in Canada and the United States (U.S,). Data came from the 2007-2008 Canadian Community Health Survey and the National Health Interview Survey. Analyses were limited to foreign-born, non-elderly adults in each country (n = 12,870 in Canada and n = 7440 in the U.S.). Health care indicators included having a usual source of care; annual consultation with a health professional, dentist, and eye doctor; flu shot in the past year; and Pap test in the past 3 years. Logistic regression models were employed to estimate the relative odds of access or use of care, adjusting for need, demographic factors, socioeconomic status, and insurance coverage. In general, rates of health care access and utilization were higher in Canada than the U.S. among all immigrant groups. In both countries, adjusted analyses indicated that immigrants with shorter length of stay (less than 10 years) and limited language proficiency generally had lower rates of access/use compared with those with longer length of stay (10 years or more) and proficiency in each country's official language(s), respectively. There was one exception to this pattern in the U.S.: immigrants with limited English had higher odds of having a recent Pap test relative to English-proficient immigrants. The persistence of disparities in health care experiences based on length of stay and language proficiency in Canada suggests that universal health insurance coverage may not be sufficient for ensuring access to and utilization of primary and preventive care for this population.

STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions

Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.

STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions

Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.

Hispanic children with special health care needs from Spanish-language households

OBJECTIVES

We examined the specific health care needs of Hispanic children with special health care needs (CSHCN) from Spanish-language households, and we compared the needs for children in this group to those for Hispanic and non-Hispanic white CSHCN from English-language households.

METHODS

We estimated the prevalence of parent-reported health care needs, health conditions, and functional characteristics by using data from the 2001 and 2005-2006 National Survey of Children With Special Health Care Needs. We used bivariate and multivariate methods to describe the relationship between ethnicity, language, and the demographic, socioeconomic, and health characteristics of CSHCN.

RESULTS

Between 2001 and 2005-2006, the prevalence of special health care needs increased significantly among Hispanic and non-Hispanic white children from English-language households but not among Hispanic children from Spanish-language households. In 2005-2006, Hispanic children from Spanish-language households were only one-third as likely as other children to be identified as CSHCN. Relative to both Hispanic and non-Hispanic white CSHCN from English-language households, Hispanic CSHCN from Spanish-language households had a higher prevalence of several developmentally related conditions and of functional difficulties related to gross and fine motor coordination, self-care, speech, and communication but had a lower prevalence of attention-deficit/hyperactivity disorder. Lower use of prescription medications was significantly associated with Hispanic ethnicity (regardless of household language) even after we controlled for demographic and socioeconomic differences.

CONCLUSIONS

Hispanic CSHCN from Spanish-language households are distinct from other CSHCN, and stratifying the Hispanic population by using primary household language can reveal important differences in the health and functioning characteristics of Hispanic CSHCN.

Development and implementation of a collaborative, multistakeholder research and practice model on HIV prevention targeting Asian/Pacific Islander men in the United States who have sex with men

We describe lessons learned from a national HIV prevention research program grounded in community-based participatory research, the Men of Asia Testing for HIV (MATH) Study, which targeted self-identified Asian/Pacific Islander men in the United States who have sex with men. We discuss the genesis of and impetus for the study and then describe its various facets, including accomplishments, challenges, and unanticipated consequences. We conclude with a discussion about the real-world practice of community-based participatory research with respect to the MATH Study in particular and similar research in general.