Racial/Ethnic Disparities inHealth and
Health Care amongU.S. Adolescents
MayLau, Hua Lin, and Glenn Flores
Objective. To examine racial/ethnic disparities in medical and oral health status,
access to care,anduse ofservices in U.S. adolescents.
Data Source. Secondary data analysis of the 2003 National Survey of Children’s
Health. The surveyfocus was children0–17 years old.
Study Design. Bivariate and multivariable analyses were conducted for white,
African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native,
and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40
measures ofhealth andhealth care.
Principal Findings. Certain disparities were especially marked for specific racial/
ethnic groups and multiracial youth. These disparities included suboptimal health
status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and
not receiving all needed medications in the past year for African Americans; no physi-
cian visit or mental health care in the past year for Asian/Pacific Islanders; overweight/
obesity, uninsurance, problems getting specialty care, and no routine preventive visit
in the past year for American Indian/Alaska Natives; and not receiving all needed den-
tal care inmultiracial youth.
Conclusions. U.S. adolescents experience many racial/ethnic disparities in health
and health care. These findings indicate a need for ongoing identification and monitor-
ing of and interventions for disparities for all five major racial/ethnic groups and
Key Words. Race/ethnicity, adolescents, disparities, health
Most pediatric research examining health and health care disparities has
focused on specific indicators, such as obesity, a usual source of care, unmet
needs, delayed care, mental health care receipt, and selected oral health
measures (Brown, Wall, and Lazar 1999; Wen 2007; Alexandre, Martins, and
Richard 2009; Bethell et al. 2009; Hoilette et al. 2009; Huang et al. 2009;
Taichman et al. 2009). Only two studies have comprehensively examined
racial/ethnic disparities among children of all ages (Flores and Tomany-
Korman 2008a; Flores 2010), but no published studies have comprehensively
examined racial/ethnic disparities in health status, access to care, and
Health Services Research
use of services. A comprehensive examination of adolescent racial/ethnic dis-
parities is crucial for identifying, monitoring, and eliminating disparities.
Adolescents 10–17 years old comprise almost 50 percent of the pediatric
population, and approximately half of adolescents are racial/ethnic minorities
(U.S. Census Bureau a 2011). Latinos are the largest racial/ethnic group of
children after whites, followed by African Americans, Asian/Pacific Islanders
(APIs), and American Indian/Alaska Natives (AI/ANs) (U.S. Census Bureau
2011). Available studies suggest that there are unique disparities for adoles-
cents (Wen 2007; Van Wie, Blewett, and Davern 2008; Adams et al. 2009;
Alexandre, Martins, and Richard 2009). For example, adolescents had higher
odds of poorer parent-rated health relative to younger children in a study of
U.S. children (Wen 2007). Poor childhood health is associated with lower edu-
cational attainment (Haas and Fosse 2008; Jackson 2009) and poor health in
adulthood (Case, Fertig, and Paxson 2005). Two studies have examined ado-
lescent disparities in overall health status and a limited number of access-to-
care and use-of-services measures (Fox et al. 2007; Mulye et al. 2009). One
study examined disparities only among three racial/ethnic groups (whites,
Latinos, and African Americans) for 12 indicators of health and health care
access and use in two national datasets, and found minority youth were more
likely to have poor or fair health (Fox et al. 2007). The other study (Mulye
et al. 2009) was a review of multiple data sources, including electronic data-
bases, articles, and reports, with a limited number of nationally representative
measures. Additional studies on overweight/obesity, dental caries, discussion
ofpreventivehealthtopics,ormental health services receipt mainly compared
whites with Latinos and African Americans or African Americans only
(Brown, Wall,andLazar 1999;Alexandre,Martins,and Richard2009;Bethell
et al. 2009). Nationally representative studies comprehensively examining
adolescent disparities in medical and oral health, access to care, and use of
services from other racial/ethnic groups, including API, AI/AN, and multira-
To understand and reduce racial/ethnic health care disparities among
adolescents, disparities must first be identified (Kilbourne et al. 2006). The
study aim, therefore, was to identify disparities in 40 health and health care
Address correspondence to May Lau, M.D., M.P.H., Division of General Pediatrics, Department
of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard,
Dallas, TX 75390-9063; e-mail: email@example.com. Hua Lin, Ph.D., and Glenn Flores,
M.D., are with the Division of General Pediatrics, Department of Pediatrics, University of Texas
Southwestern Medical Center. May Lau, M.D., M.P.H., and Glenn Flores, M.D., are also with
2032 HSR: Health Services Research 47:5 (October 2012)
measures in a nationally representative, racially/ethnically diverse sample of
adolescents. The study hypothesis was that multiple disparities in medical and
oral health, access to care, and use of services would be identified in this
nationally representative, racially/ethnically diverse sample of adolescents.
The 2003 National Survey of Children’s Health (NSCH) was a cross-
sectional, random-digit-dial household telephone survey conducted by the
National Center for Health Statistics (NCHS) (Blumberg et al. 2005). The
NSCH provides national and state estimates of a variety of physical, emo-
tional, and behavioral health indicators. From January 2003 to July 2004,
102,353 interviews were completed for children 0–17 years old in all 50 states
and the District of Columbia. Survey respondents were parents or guardians
(hereafter referred to as parents) who were most knowledgeable about the
health and health care of the children in the household. The index child for
the survey was randomly selected. All interviews were conducted in English
The NSCH Spanish survey was translated from the English version by
an experienced Spanish health survey translator and reviewed for accuracy
and cultural appropriateness by NSCH telephone interviewers and supervi-
sors. Parents not speaking English or Spanish were excludedfrom the NSCH.
To obtain nationally representative estimates ofhealth and health care dis-
parities for API and AI/ANadolescents, the nonpublic NSCH dataset was ana-
lyzed. Although similar to the public dataset, the nonpublic dataset allows
The NSCH used computer-assisted telephone interviewing system,
which minimizes missing data (Blumberg et al. 2005). Nevertheless, any
records with missing data were not included in these analyses.
Definitions and Variables
adolescent’s age, gender, race/ethnicity, and primary language spoken at
home; the number of adults and children in the household; employment
status and highest educational attainment of an adult in the household; and
characteristicsreportedby parents included the
Racial/Ethnic Disparities inHealth andHealth Care2033
household poverty status (using the federal poverty threshold [FPT] for a
family of four at the time of the survey). A child was considered multiracial
if the parent selected more than one race/ethnicity. Body mass index (BMI)
was calculated using parental reports of the adolescent’s height and weight.
The study variables consisted of a subset of 40 health and health care mea-
sures (Table 1).
To account for the complex sample design of NSCH and to produce weighted
estimates,allanalyseswere performedusing STATA 10(StataCorp2007). Ado-
lescents were defined as 10–17 years old, consistent with the Society of Ado-
lescent Health and Medicine’s definition of adolescence as beginning at
10 years old (Society for Adolescent Medicine 1995). The conceptual frame-
work for this study was the life-course model, which posits that adolescence is
a critical or sensitive developmental period in which events can positively or
negatively impact future health, underscoring the importance of research
focused on identifying racial/ethnic disparities specific to adolescents (U.S.
Department of Healthand Human Services 2010).
The 40 different health and health care variables examined measures in
three domains: medical and oral health status, access to care, and use of
services. These domains and variables were selected to provide a comprehen-
sive picture of racial/ethnic disparities. The sociodemographic characteristics
of all adolescents and their households were compared, followed by bivariate
analyses to identify disparities between white and racial/ethnic minority
adolescents in health and health care. Bivariate analyses were done using the
chi-square and Wilcoxon nonparametric tests. Statistical significance was
considered to be atwo-tailed p < .05.
Multivariable logistic regression analyses were performed to examine
adjusted associations between race/ethnicity and health and health care out-
comes. Covariates in each model included the adolescent’s age, primary lan-
guage spoken at home, insurance coverage (except when this was the
outcome), employment status and highest educational attainment of an adult
in the household, number of adults and children in the household, and house-
hold poverty status. All multivariable analyses employed stepwise procedures
followed by forced entry of significant covariates from the stepwise model to
obtain the final weighted odds ratios and 95 percent confidence intervals; the
initial alpha-to-enter was 0.15, and the final alpha-to-enter was 0.05.
Consistent with prior NSCH analyses (Flores and Tomany-Korman 2008b)
2034 HSR:Health Services Research 47:5 (October 2012)
Study Variable List from the 2003 National Survey of Children’s
Ingeneral,howwouldyoudescribe[CHILD’s NAME] health?
Howtallis [CHILD’s NAME]?
Does [CHILD’s NAME] needor usemoremedical care,mental health,
or educational servicesthanis usualformostchildrenofthesameage?
Is[CHILD’sNAME]limitedor preventedinany wayin his/herability
todo thethingsmostchildrenofthesameage cando?
Does [CHILD’s NAME] needor getspecial therapy,such asphysical,
occupational,or speech therapy?
Overall, doyouthinkthat[CHILD’s NAME] hasdifficultieswithone
or moreofthefollowing areas:emotions,concentration,behavior,
or beingabletogetalong withotherpeople?
Does [CHILD’s NAME] haveanykindofemotional, developmental,
or behavioral problem forwhichhe/sheneedstreatmentor
Hasa doctor,health professional,teacher, orschoolofficial evertold
Hasa doctoror healthprofessionalevertoldyouthat[CHILD’s
Attentiondeficit disorderor attentiondeficit hyperactivedisorder
Duringthe past12 months,haveyoubeen toldby adoctoror other
Racial/Ethnic Disparities in Health andHealth Care2035
Skin Eczema orany kindofskinallergy
Stuttering,stammering,or otherspeech problems
Teethcondition Howwouldyoudescribetheconditionof[CHILD’s NAME]’steeth:
Does [CHILD’s NAME] haveanykindofhealthcarecoverage,
includinghealth insurance,prepaidplanssuchas HMOs,or
Duringthepast12 months,wasthere anytimewhenhe/shewasnot
Does [CHILD’s NAME] haveinsurancethathelpspayfor anyroutine
Duringthepast12 months,did[CHILD’s NAME] receiveall the
Whydid[CHILD]notgetall medical carethat[he/she]needed?
Howmuch ofa problem,if any,wasit togetthecarefromthe
Duringthepast12 months,didhe/shereceiveall theprescription
Duringthepast12 months,didhe/shereceiveall theroutine
Whydid[CHILD’sNAME]not getallthedental carehe/sheneeded?
see adoctor,nurse,or otherhealthcareprofessionalfor preventive
medicalcaresuchasa physicalexamor well-childcheckup?
go toa hospitalemergencyroomabouthis/her health?
Duringthepast12 months,did[CHILD’s NAME] receiveany
2036HSR: Health Services Research 47:5 (October 2012)
and published guidelines (Perneger 1998), a Bonferroni correction was not
performed, given that a specific a priori hypothesis was tested (minority
racial/ethnic adolescents and whites significantly differ in medical and oral
health, access to care, and use of services, after adjustment for covariates) for
each dependent variable, rather than testing a universal null hypothesis or
conducting an analysis without any a priori hypothesis. Pearson and deviance
residuals, studentized residual, hat matrix diagonal (Hoaglin and Welsch
1978), Cook’s distance (Belsley et al. 1980), and the COVRATIO (Cook and
Weisberg 1982) from the changes of the covariance matrixes were examined
to identify the influential data points and outliers in the regression diagnostics
process. No influential data points or outliers were identified using any of
these procedures. The p values for model fit statistics ranged from <.01 to .02.
The log likelihood chi-square tests for all models were significant. After each
logistic regression, pseudo R, Hosmer and Lemeshow goodness-of-fit test, the
Akaike Information Criterion, and the Bayesian Information Criterion were
used to selectthe optimallyfitted model (Chen et al., n.d.).
Sociodemographics. A total of 48,742 completed interviews were analyzed for
adolescents 10–17 years old. The mean age of adolescents from different
racial/ethnic groups slightly differed (Table 2). Latino households had the
highest percentages of having no high-school graduate, the primary language
Abouthowlonghasit beensincehe/shelastsaw adentist?
Duringthepast12 months,did[CHILD’s NAME] seea dentistfor
any routinepreventivedentalcare,includingcheckups, screenings,
Duringthepast12 months,did[CHILD’s NAME] useanyprescription
Duringthepast12 months,wasthere anytimewhen[CHILD’sNAME]
Duringthepast12 months,did[CHILD’s NAME] useanyprescription
Racial/EthnicDisparities in Health andHealth Care2037
Old by Race/Ethnicity
Meanor Proportionfor Each Racial/EthnicGroup
attainmentin household (%)
Number ofchildrenin household(%)
24.5 33.035.48.3 33.221.8
73.338.4 56.690.3 57.173.1
2038HSR: Health Services Research 47:5 (October 2012)
spoken at home was not English, and >3 children at home. Over 1/4 of Latino,
API, and AI/AN households had >2 adults living in the home.
White households were most likely to have an adult employed
?50 weeks in the past year (Table 2). Close to 1/3 of Latino and AI/AN
households had a family income <100 percent of the FPT.
Medical and Oral Health Status. Medical health status: White, API, and multira-
cial adolescents had the highest percentages of optimal (excellent or very
good) health (Table 3). Obesity/overweight was identified in approximately
40 percent of AI/AN, African American, and Latino adolescents. AI/AN,
African American, and multiracial adolescents had the highest proportions of
asthma. AI/AN adolescents had the highest prevalence of hearing/vision
problems and bone/joint/muscle problems. Respiratory allergies were most
prevalent in multiracial youth and skin allergies in African Americans. AIs/
ANs had the highest rates of ?3 ear infections in the past year and APIs had
the lowest rates. Higher proportions of parents of AI/AN, multiracial, and
white adolescents reported needing more medical care than others. AI/AN
adolescents were more likely to have limited abilities and need/get special
Behavioral, developmental, and emotional health: African American adoles-
cents had the highest prevalence of behavior problems (Table 3). Attention
racial adolescents. African American, multiracial, and Latino adolescents had
similar percentages for speech problems. AIs/ANs were most likely to have a
learning disability. African American, multiracial, and AI/AN adolescents
have the highest proportions for difficulty with emotions, concentration,
behavior, or interpersonal relations. AI/AN adolescents had the highest prev-
Oral health status: The teeth condition was suboptimal (not excellent/
very good) in over halfof Latino adolescents(Table 3).
Access to Medical and Dental Care. Latino and AI/AN adolescents were signifi-
cantly more likely to be uninsured than white children, and Latino, African
American, and AI/AN adolescents had higher proportions of sporadic insur-
ance coverage (Table 3). Public insurance coverage was greatest among Afri-
can American, AI/AN, and Latino adolescents. Latino and AI/AN
adolescentshad the lowest rates of dental insurance.
Racial/Ethnic Disparities in Health andHealth Care 2039
Medical and Oral Health, Access to Care, and Use of Services among U.S.
Bivariate Analysis of the Association of Racial/Ethnicity with
P White Latino
5.2 3.4 4.4 126.96.36.199.0001
13.4 11.411.8 3.8 19.215.5
5.95.7 9.62.6 7.26.8.0001
2040 HSR: Health Services Research 47:5 (October 2012)
Access tomedical anddentalcare
Reasonforunmet medicalcareneed (%)**
4.11.9 2.8 188.8.131.52 .0001
Racial/EthnicDisparities inHealth and Health Care2041
P White Latino
Useofmedical and dentalservices
in pastyear (%)
2.33.4 5.3 0.92.6 1.8
0.90.5 2.400 1.1.0001
8.917.6 6.67.3 1.310.3 .02
25.736.3 184.108.40.206 26.0
26.116.0 21.4 14.423.0 26.9
†BMI, body mass index; overweight was defined as a BMI = 85–94 percent for age and gender,
andobesewasdefinedasa BMI ? 95percentfor ageandgender.
‡Includes physical,occupational, orspeechtherapy.
§Onlyif made adental visitin past12 months.
¶Onlyif madea physicianvisit inpast12 months.
**Onlyaccessbarrierswithsignificantracial/ethnic disparitieslisted; seetextfor otherbarriers.
††Onlyamongthosewhohaveevermade adental visit.
2042HSR: Health Services Research 47:5 (October 2012)
Latino and AI/AN adolescents had the lowest proportions of having a
personal doctor or nurse (PDN), and AI/AN adolescents had the lowest pro-
portion of receiving all needed medical care (Table 3). Multiracial and white
adolescents had the highest percentages of unmet medical needs due to the
doctor not knowing how to provide care. About half of APIs and AIs/ANs
had problems getting specialty care. African American adolescents had the
highest prevalence of not receiving all needed prescription medications in the
African American, multiracial, and Latino youth were least likely to
receive all needed dental care (Table 3). Unmet dental care needs due to the
dentist not knowing how to provide care were seen most often in African
American youth, and due to a health-plan problem most often among Latino
and multiracial youth.
Use of Medical and Dental Care. Over 1/3 of Latino, API, and AI/AN adoles-
cents did not have a physician visit in the past year (Table 3). Higher percent-
ages of AI/AN, African American, and multiracial adolescents had ?3 visits
to the emergency department (ED). Greater numbers of African American
and Latino adolescents did not receive needed prescription medications in the
Latino adolescents had the highest risk of never seeing a dentist
(Table 3). Among adolescents who ever made a dental visit, AI/ANs were
most likely tohave not made apreventive dental visit in the past year.
Medical and Oral Health Status. Medical health: Compared with white adoles-
cents, Latino and African American adolescents had significantly greater
odds of suboptimal health status (Table 4). AI/AN, African American, and
Latino adolescents had higher odds of overweight/obesity and having
asthma. AI/ANs had higher odds of having hearing/vision problems, and
African Americans and APIs had lower odds. API adolescents had lower
odds of bone/joint/muscle problems and diabetes, whereas African Ameri-
can adolescents had lower odds of diabetes. African American, AI/AN,
and multiracial adolescents had greater odds of having skin allergies. Afri-
can American and API adolescents had lower odds of having >3 ear infec-
tions in a year. African Americans and APIs had lower odds of needing
more medical care than others. AI/ANs had higher odds of having limited
Racial/Ethnic Disparities in Health andHealth Care 2043
Multivariable Analysis of Racial/Ethnic Disparities in Medical and Oral Health Status, Access to Care, and
Useof Services among U.S. Adolescents
Medicalandoral health status
Needs/gets special therapy
behavior,or interpersonal relations
problemsneeding treatmentor counseling
2044HSR: Health Services Research 47:5 (October 2012)
Table 4. Continued
Teethcondition notexcellent/very good*
Accesstomedical anddental care
Didnot receive all neededmedical care‡
Reasonfor unmetmedical careneed
Noone accepts child’sinsurance
Didnot receive all neededprescription
Didnot receive all neededdental care§
Reasonfor unmetdental careneedd
Noone accepts child’sinsurance
Racial/Ethnic Disparities in Health andHealth Care2045
Table 4. Continued
No dental insurance
Use ofmedical anddentalservices
No physicianvisit in pastyear
Oneor moreEDvisits in pastyear
Received nomental healthcarein
No routinepreventive dental visit in
Received nomental healthcarein pastyear
Notgiven prescription medicationin
Note. Adjusted for primary language spoken at home, child’s age and medical insurance coverage, highest educational attainment and employment sta-
tusofadultin household,numberofchildrenin the household,numberofadultsinthe household,andpovertylevel.
*Adjusted for dental, rather than medical, insurance coverage, as well as child’s age, highest educational attainment and employment status of adult in
household,numberofchildrenandadultsin thehousehold,andpoverty status.
†Adjusted for primary language spoken at home, child’s age, highest educational attainment and employment status of adult in household, number of
children inthehousehold,numberofadultsin thehousehold,andpoverty level.
‡Onlyif made a physicianvisit inpast12 months.
§Only for those making a dental visit in past 12 months; adjusted for primary language spoken at home, child’s age and dental insurance coverage, edu-
cational attainment and employment status of an adult in household, number of children in the household, number of adults in the household, and pov-
2046 HSR: Health Services Research 47:5 (October 2012)
abilities. API adolescents had lower odds of needing/getting special
Behavioral, developmental, and emotional health: Latino and African Ameri-
can adolescents had lower odds of ADHD (Table 4). African American and
API adolescents had lower odds than whites of having a learning disability.
African American and multiracial adolescents had greater odds than whites of
having difficulty with emotions, concentrations, behavior, or interpersonal
relations. African American adolescents had lower odds of developmental
delay and emotional, developmental, or behavioral problems needing
treatment or counseling. African Americans and APIs had lower odds of
depression and anxiety.
Oral health status: Compared with white adolescents, Latino, African
American, andmultiracial adolescentshadsignificantly greateroddsofsubop-
timal teeth condition (Table 4).
Access to Medical and Dental Care. AI/AN, Latino, and African American ado-
lescents had significantly greater odds than white adolescents of being unin-
sured and sporadically insured (Table 4). AIs/ANs had greater odds and
AfricanAmericans lower odds of having no dental insurance.
All minority racial/ethnic groups except for APIs had higher odds than
whites of having no PDN (Table 4). AI/AN, African American, and multira-
cial youth had greater odds of not receiving all needed medical care. API ado-
lescents had over 26 times the odds and multiracial adolescents had over eight
times the odds of an unmet medical care need due to a health-plan problem.
Parents of AI/AN and multiracial youth had lower odds of citing uninsurance
as a reason for unmet needs, whereas African American parents had lower
odds of identifying cost as a reason for unmet medical needs. AI/AN parents
had higher odds of citing transportation as a reason for unmet medical needs.
Latino and AI/AN parents had over 11 times the odds of reporting treatment
is ongoingas reason for unmet medical needs.
AI/AN, API, and Latino adolescents had greater odds than whites of
problems getting specialty care (Table 4). Only African American adolescents
had greater odds of not receiving all needed prescription medications in the
Multiracial and African American adolescents had greater odds than
whites of not receiving all needed dental care (Table 4). APIs and AI/ANs had
higher odds of unmet dental needs due to transportation problems and incon-
venient times/not being able to get an appointment. African American, API,
Racial/EthnicDisparities in Health andHealth Care 2047
and AI/AN adolescents had lower odds of cost as a reason for unmet dental
needs. AI/AN adolescents had higher odds for unmet dental needs due to
Useof Medical Care,DentalCare,andPrescriptionMedications. African American,
API, and AI/AN adolescents had greater odds than white adolescents of no
had greater odds of no routine preventive dental visit in the past year
(Table 4). API adolescents had lower odds of having ?1 ED visit in past year.
African American and API adolescents had double the odds of no mental
health care in the past year but lower odds of needing/using prescription med-
ications. All minority groups except for AI/ANs had higher odds of not being
given a prescription medication in the past year.
This study comprehensivelydocumentsmultiple disparities among racial/eth-
nicminority U.S.adolescents in three domains: medical andoral health status,
access to care, and use of services. Compared with white adolescents, Latino,
African American, and multiracial youth were less likely to have excellent/
very good teeth condition; all minority racial/ethnic groups, including multi-
racial youth, were less likely to have health insurance and a preventive dental
visit in the past year; Latino, African American, and AI/AN youth were less
likely to have a PDN; and Latinos, APIs, and AI/ANs were less likely to have
no physician visit in the past year. Latinos, African Americans, and AIs/ANs
had greater odds than whites of being overweight/obese and having asthma;
African American, AI/AN, and multiracial youth had greater odds of having
skin allergies and not receiving all needed medical care; and Latino, API, and
AI/AN youthhad greater odds ofproblems getting specialty care.
Specific racial/ethnic groups had noteworthy disparities. Latino adoles-
cents had the highest proportions of any group of having no health insurance.
Despite improvement in insurance-coverage rates of children through the
Children’sHealth Insurance Program andMedicaid, Latino children continue
to experience greater odds of uninsurance than whites (Flores and Tomany-
Korman 2008a; Van Wie, Blewett, and Davern 2008). Research suggests that
older age of the child, parental immigrant status, both parents working, and
certain lower income categories are associated with uninsurance in Latino
2048HSR: Health Services Research 47:5 (October 2012)
children,indicating that uninsuranceislikelyduetotheprevalenceofsociode-
mographic factors, not Latino ethnicity (Flores, Abreu, and Tomany-Korman
2006). Over 1/3 of Latino adolescents do not have a usual source of care, the
highest prevalence of any racial/ethnic group, consistent with prior work
(Wen 2007; Flores and Tomany-Korman 2008a; Hoilette 2009), and likely
reflects the high ratesof uninsurance.
African American adolescents had the highest number of medical and
oral health status disparities of any racial/ethnic group, with significantly
higher adjusted odds than white adolescents for six measures. Dental health
and dental care disparitieswere noted in African American children of all ages
in a nationally representative study (Flores and Tomany-Korman 2008a). Our
study identified analogous dental issues, with African American adolescents
having the highest proportions of not receiving all needed dental care and the
highest adjusted odds of suboptimal teeth condition. Other research shows
African American children having lower odds of receiving needed specialty
dental care and higher odds than white children of untreated dental caries
(Brown, Wall, and Lazar 1999; Taichman et al. 2009). Geography may
account for African American adolescents’ high number of health status dis-
parities; African American children are more likely to be poorer, live in more
disadvantaged neighborhoods, and more likely to experience double jeop-
ardy (to be poor and live in a high-poverty neighborhood) compared with
white children (Acevedo-Garciaet al. 2008).
African American and API adolescents had lower adjusted odds than
whites for certain health and health care indicators, including depression/anx-
iety, diabetes, and >3 ear infections. These disparities were one to three times
lower odds for African Americans and 2 to over 30 times lower odds for APIs
compared with whites. Previous research has documented African American
children to be less likely to be diagnosed with frequent ear infections (Vakha-
ria, Shapiro, and Bhattacharyya 2010) and African American and API chil-
dren of all ages to have lower odds of several health and health care indicators
(Flores and Tomany-Korman 2008a), but this is the first study (to our knowl-
edge) to report these findings in African American and API adolescents.
Lower odds of physician-diagnosed conditions may reflect access-to-care bar-
riers, which have been previously documented (Huang et al. 2009; Bhatta-
charyya, Shapiro, and Vakharia 2010), but the NSCH data do not provide
possible reasonsfor these findings.
Conversely, APIs had substantially higher adjusted odds than whites of
citing transportation and inconvenient times/could not get an appointment as
reasons for unmet dental needs. Reasons for unmet dental needs for API
Racial/Ethnic Disparities in Health andHealth Care2049
youth have not been previously documented in the literature, although adult
cultural beliefs (preventive habits controlling dental disease and the impor-
tance ofsecondary teeth over primaryteeth) havebeen shown tobeassociated
with preventive dental care access in young Chinese children (Wong,
Perez-Spiess, and Julliard 2005; Hilton, Barker, and Weintraub 2007). API
adolescents had substantially higher adjusted odds for no physician visit, not
receiving mental health care, and needing but not given prescription medica-
tions in the past year. Employment responsibilities, long physician waiting
times, and cultural beliefs have been cited as reasons for delayed health care
(Huang et al. 2009) and may contribute to low physician visit rates and possi-
bly unmet dental needs for API adolescents. Lack of receipt of mental health
care only has been demonstrated in high-risk APIyouth (Garlandet al.2005).
American Indian/Alaska Native adolescents had the highest number of
disparities of any minority group at 18. AI/AN adolescents had the highest
adjusted odds of overweight/obesity and asthma. These study findings are
consistent with previous researchindicating a higher obesity and asthma prev-
alence in AI/AN children (Zephier et al. 2006; Meng et al. 2007; Brim et al.
2008; Flores and Tomany-Korman 2008a; Singh, Siahpush, and Kogan 2010).
AI/AN adolescents also had the highest adjusted odds for eight other indica-
tors, including no health and dental insurance, no PDN, not receiving all
needed medical care, treatment is ongoing as a reason for unmet medical care
and dental care needs, problems getting specialty care, and no preventive den-
tal visit in the past year. Although these findings were previously noted in AI/
AN children of all ages (Flores and Tomany-Korman 2008a), to our knowl-
edge, this is the first report of these disparities in AI/ANadolescents. Previous
research has documented higher rates of uninsurance, problems accessing
health care, and health care use for AIs/ANs (Zuckerman et al. 2004). Most
AIslive inurbanareas,notonareservation, ordonotbelong tooneofthefed-
erally recognized tribes, limiting access to the Indian Health Service and may
account for the high number of AI adolescent health disparities (Brown et al.
2000; Zuckerman et al.2004).
Very little published information exists on disparities in multiracial ado-
lescents (Kogan et al. 2007; Lewis et al. 2007a,b), probably due to the smaller
sample sizes available in national databases. Multiracial adolescents had par-
ticularly high odds of difficulty with emotions, concentration, behavior, or
interpersonal relations, and not receiving all needed dental care. This is the
first study, to our knowledge, detailing multiracial adolescent health and
health caredisparitiesinanationalsample.Researchhasdocumented multira-
cial children having a lower likelihood of autism-spectrum disorder and a
2050HSR: Health Services Research 47:5 (October 2012)
preventive dental visit in the past year (Kogan et al. 2007; Lewis et al. 2007a).
Without the inclusion of multiracial adolescents,uniqueand important dispar-
ities would have been overlooked and not documented. A possible reason for
newly identifiedmultiracialyouth disparitiesisprovidingmultiracialrace/eth-
nicity as a choice, rather than grouping an individual into a self-reported “best
race category”(Bratterand Gorman2011).
Our study findings documented several unique adolescent racial/ethnic
disparities, when compared with a recent study of racial/ethnic disparities
among children of all ages (Flores and Tomany-Korman 2008a). In contrast to
nonsignificant findings in children of all ages, significantly higher odds versus
whites were seen in African American adolescents for no health insurance and
not receiving all needed medical care; in API adolescents for unmet medical
needs due to a health-plan problem and no preventive dental visit in the past
year; and in AI/AN adolescents for having limited abilities, asthma, hearing/
vision problems, skin allergies, problems getting specialty care, and no pre-
ventive dental visit in the past year. Multiple disparities for minority children
of all ages were not observed in minority adolescents. These findings highlight
that racial/ethnic disparities among children of all ages do not necessarily per-
tain to adolescents and support studies on disparities examining adolescents
separately from younger children.
Certain study limitations should be noted. Health and health care dis-
parities in racial/ethnic subgroups and AI/AN tribal groups could not be
examined, given that this information is not available in the NSCH. All infor-
mation was obtained via parental report, not medical records, so the preva-
lence of medical conditions may not be accurate. The NSCH records the
primary language spoken at home, but not parental English proficiency, even
though research demonstrates the latter to be more useful for examining
health and health care measures (Flores, Abreu, and Tomany-Korman 2005).
An unknown number of households with parents who had limited proficiency
in English and Spanish were not included, given that the NSCH was only con-
ducted in English or Spanish. As a result, it is likely that a larger proportion of
parents with limited English proficiency (LEP) of Latino adolescents were
included in the NSCH, compared with LEP parents of API adolescents.
Immigration status was not examined in the NSCH, but it has been associated
with medicalandoralhealthstatus,obesity,health insurancecoverage,mental
health care,and ausual sourceofcare(Huang,Yu,and Ledsky 2006;Maserej-
ian et al. 2008; Weathers et al. 2008; Singh, Kogan, and Yu 2009). Adjust-
ment for gender was not done in multivariable analyses, because published
research is conflicting regarding the association of gender with access-to-care
Racial/EthnicDisparities inHealth and Health Care 2051
and use-of-services outcomes (Ford, Bearman, and Moody 1999; Shenkman,
Youngblade, and Nackashi 2003; Sarmiento et al. 2004; Lehrer et al. 2007).
Disparities were not separately examined in younger and older adolescents.
Health and health care disparities were identified by analyzing the NSCH
database, but such a cross-sectional study cannot provide insights on why spe-
cific race/ethnicities experience certain disparities.
Specific study strengths should be noted. The analyses examined all five
ally representative sample of over 48,742 adolescents, with analyses of 40
measures in three domains: medical and oral health status, access to care, and
use of services. This study provides a comprehensive examination of racial/
ethnic disparities, focusing solely on adolescents 10–17 years old. Previous
researchhas concentrated on a single disparity or defined adolescence as start-
ingat12 yearsold(Deitrichet al.2008;Singh,Siahpush,andKogan2010).
The 2003 NSCH dataset was the most up-to-date dataset available at the
time of this analysis. To gain access to the 2003 NSCH nonpublic dataset,
NCHS approval was needed, and analyses need to be performed at the
NCHS Research Data Center. Analyses of the 2007 NSCH will be reported
in a separate paper by our team as part of a trend analysis of adolescent racial/
ethnic disparities in the United States comparing the 2007 and 2003 NSCH
databases. Initial analyses of the nonpublic 2007 NSCH database were con-
ducted in the third quarter of 2010, in collaboration with the NCHS.
The study findings have several research, practice, and policy implica-
tions. Unique adolescent racial/ethnic disparities have been identified; these
disparities would have been missed if adolescents were not examined sepa-
rately from younger children, possibly affecting future research, practice, and
policy. Newly identified disparities in AI/AN, API, and multiracial adoles-
cents underscore the need for data collection, analysis, and monitoring of dis-
parities for all five major racial/ethnic groups and multiracial adolescents.
Toolkits have been developed to educate hospital staff on the importance and
collection of race/ethnicity data (Health Research and Educational Trust).
Along with race/ethnicity, immigration status, immigration generational sta-
tus, the primary language spoken at home, and LEP are variables for which
data could be collected nationally to identify and monitor disparities. Many
racial/ethnic disparity studies continue to combine minority children into a
single nonwhite category or do not include a comparison group of white chil-
dren (Flores 2010). Disparity studies primarily have focused on African Amer-
ican and Latino children; few studies exist on APIand AI/AN children (Flores
2010) and no studies exist on multiracial youth. Inclusion of APIs in health
2052 HSR: Health Services Research 47:5 (October 2012)
disparities research, however, is supported by a recent study of a nationally
representative sample of racially/ethnically diverse children of all ages dem-
onstrating Latino and Asian children as the two groups with the worst health
care quality (Berdahl et al. 2010). Multiracial individuals need to be examined
separately from other racial/ethnic groups, given that recent work demon-
strates that placing multiracial individuals into a single racial/ethnic group
masks disparities (Bratterand Gorman 2011).
The study findings might prove useful for practitioners, hospitals, and
policy makers indeveloping and evaluating interventionsto reduce disparities
in minority youth. Practitioners could use these study findings to identify dis-
parities within their practice and develop effective interventions (Chin, Alex-
ander-Young, and Burnet 2009). The American Academy of Pediatrics
provides grants to practitioners to develop community-based initiatives that
can involve schools and social service agencies; these grants are aimed at
improving children’s health and reducing/eliminating disparities (American
Academy of Pediatrics 2011). Hospitals also can implement interventions to
reduce adolescent disparities. Although many hospitals collect race/ethnicity
data, hospitals are not always aware of how to use the data and develop effec-
tive interventions (Regenstein and Sickler 2006). The American Hospital
Association has developed a guide for hospital leaders to improve collection
of race/ethnicity data, identify and track disparities, and develop effective
interventions (Health Research and Educational Trust 2011). Racial/ethnic
minority adolescents have increased to 43 percent in 2009 from 39 percent in
2003, according to the latest available data (U.S. Census Bureau n.d.a, b, c, d),
so federal and state policy makers can use these findings, in conjunction with
an upcoming trend analysis by our team on U.S. adolescent racial/ethnic dis-
parities, to inform, target, and enact policy at schools, social agencies, and
other sites toaddress specificadolescent disparities.High ratesofuninsurance,
especially for foreign-born children (Pati and Danagoulian 2008), and the
multiple identified nonfinancial barriers to care suggest an urgent need to
improve access to care for minority youth by policy makers. Recent health
care reform legislation targeted increasing the pediatric work force, establish-
ing quality-of-care priorities, enhancing preventive pediatric services to
include oral and vision services, expanding Medicaid, increasing Medicaid
ment status (The Commonwealth Fund 2010a,b; The White House, n.d.). The
study findings suggest that these measures could help reduce or eliminate
many racial/ethnic disparities in the health and health care of adolescents.
Racial/Ethnic Disparities inHealth andHealth Care 2053
Joint Acknowledgment/DisclosureStatement:Thisproject was supported in part by
the Network for Multicultural Research on Health and Healthcare, Depart-
ment of Family Medicine, David Geffen School of Medicine, U.C.L.A.,
fundedby the Robert Wood Johnson Foundation.
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