Racial and ethnic disparities in the quality of primary care for children
Studies of primary care among adults, however, are not readily applicable to children for several reasons.25 First, a unique set of primary care financing, organization, and delivery systems has been developed for children. Examples include the recent State Children’s Health Insurance Program and nontraditional delivery settings such as school-based health centers. Second, childhood is a unique developmental stage of life during which children’s health care experiences strongly influence their future health and health care utilization. Third, primary care for children emphasizes preventive care rather than acute care as for adults and therefore must be evaluated differently.
Racial and ethnic disparities in primary care quality have rarely been studied for children.26 Although several studies have evaluated racial differences in children’s use of primary care services, few have evaluated racial differences in more qualitative primary care experiences. Weech-Maldonado and colleagues, conducting the only study of this type, found that Asian, black, and Hispanic children experienced poorer access, timeliness to care, and communication with providers compared to whites. However, language appeared to play an important factor in these disparities.27
The purpose of this study was to examine racial and ethnic differences in the quality of primary care specifically for children. Primary care was uniquely assessed, pursuant to the Institute of Medicine’s definition, with the use of a reliable and valid instrument asking parents to report on, rather than rate, the quality of care for their children. The study sought to identify deficits in primary care quality among children to lay groundwork for the development of clinical strategies and health care policies to eliminate health disparities.
Methods
Study design and setting
A cross-sectional community-based survey was conducted in a random sample of 1200 parents of elementary school children in 1 school district. The district spans 3 large suburban communities in San Bernardino County, California, near Los Angeles. The area encompasses a population of about 300,000 and approximately 17% of the population live in poverty. In San Bernardino County, there are 72.5 health care providers per 100,000 inhabitants; this rate is lower than the overall rate of 90 providers per 100,000 for the State of California.28 Because the county has several rural areas (with low physician presence) that are not served by the school district, the physician ratio is likely to be an underestimate for the more urban geographic area under study.
A school district was selected as the setting for this study because it provides the single most comprehensive list of children in a community. A community sample avoids the biases associated with research based in provider settings that generally include only the most frequent users of health services.
The school district serves a population of 18,000 racially and socioeconomically diverse elementary school children in 20 elementary schools (kindergarten through grade 6). The racial and ethnic makeup of the population is approximately 43% Hispanic; 42% white; 10% Asian, Filipino, and Pacific Islander; 5% black; and fewer than 1% American Indian. The sampling frame was sorted and systematically sampled by the child’s sex, grade level, and school strata to ensure that the sample was representative of the community. To improve the analytic capacity of the sample, Asian and black subgroups were oversampled at 4 times the rate for Asians (compared with whites) and 16 times the rate for blacks to obtain approximately equal numbers of respondents across racial and ethnic groups.
In San Bernardino County, as in a growing number of other counties in California and throughout the United States, non-white racial and ethnic groups are beginning to represent more of the population. In this study, Hispanics are the numerical majority, but we continue to use the term “minority” to represent Asian, black, and Hispanic racial and ethnic groups because in most areas of the United States these groups continue to be the numerical minority.
Data collection
The Johns Hopkins University Office for Research Subjects approved the survey instrument and administration procedures. Questionnaires were administered through structured telephone interviews between November 2000 and January 2001.
Two rounds of informational mailers were sent to parents in advance of contact by telephone. To maintain legal privacy protections for parents, clerks employed by the school district made initial contact with families to schedule appointments for interviewers to complete the telephone interview. Reminder letters were mailed to parents who had scheduled an appointment but were not reached by telephone contact.
Of the original sample of 1200 children, 289 families had moved or left the school district, disconnected their telephone number, or had a telephone number that was busy or not answered on repeated (10+) attempts; 59 families were unable to participate because of language difficulties. Parents who reported to the study clerks that they were unable to complete the survey in English or Spanish were excluded from participation. Negative terming of 2 questions and alternate wording of 2 similar questions were used to check comprehension. Concern was raised in 1 case, but this was resolved through follow-up questioning.
