Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence.

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Policy solutions to eliminate racial and ethnic child health disparities in the USA.

Societal systems act individually and in combination to create and perpetuate structural racism through both policies and practices at the local, state, and federal levels, which, in turn, generate racial and ethnic health disparities. Both current and historical policy approaches across multiple sectors-including housing, employment, health insurance, immigration, and criminal legal-have the potential to affect child health equity. Such policies must be considered with a focus on structural racism to understand which have the potential to eliminate or at least attenuate disparities. Policy efforts that do not directly address structural racism will not achieve equity and instead worsen gaps and existing disparities in access and quality-thereby continuing to perpetuate a two-tier system dictated by racism. In Paper 2 of this Series, we build on Paper 1's summary of existing disparities in health-care delivery and highlight policies within multiple sectors that can be modified and supported to improve health equity, and, in so doing, improve the health of racially and ethnically minoritised children.

Eliminating health care inequities through strengthening access to care.

OBJECTIVE: To provide a research agenda and recommendations to address inequities in access to health care. DATA SOURCES AND STUDY SETTING: The Agency for Healthcare Research and Quality (AHRQ) organized a Health Equity Summit in July 2022 to evaluate what equity in access to health care means in the context of AHRQ's mission and health care delivery implementation portfolio. The findings are a result of this Summit, and subsequent convenings of experts on access and equity from academia, industry, and the government. STUDY DESIGN: Multi-stakeholder input from AHRQ's Health Equity Summit, author consensus on a framework and key knowledge gaps, and summary of evidence from the supporting literature in the context of the framework ensure comprehensive recommendations. DATA COLLECTION/EXTRACTION METHODS: Through a stakeholder-engaged process, themes were developed to conceptualize access with a lens toward health equity. A working group researched the most appropriate framework for access to care to classify limitations identified during the Summit and develop recommendations supported by research in the context of the framework. This strategy was intentional, as the literature on inequities in access to care may itself be biased. PRINCIPAL FINDINGS: The Levesque et al. framework, which incorporates multiple dimensions of access (approachability, acceptability, availability, accommodation, affordability, and appropriateness), is the backdrop for framing research priorities for AHRQ. However, addressing inequities in access cannot be done without considering the roles of racism and intersectionality. Recommendations include funding research that not only measures racism within health care but also tests burgeoning anti-racist practices (e.g., co-production, provider training, holistic review, discrimination reporting, etc.), acting as a convener and thought leader in synthesizing best practices to mitigate racism, and forging the path forward for research on equity and access. CONCLUSIONS: AHRQ is well-positioned to develop an action plan, strategically fund it, and convene stakeholders across the health care spectrum to employ these recommendations.

Policing and Overuse of the Juvenile Justice System.

National attention toward recent highly publicized police killings and the coronavirus disease 2019 pandemic, which has disproportionately impacted communities of color, highlight the continued systematic oppression of racial and ethnic minorities in the United States. Furthermore, burgeoning evidence demonstrates that police contact is associated with adverse health outcomes for Black and Latinx youth beyond the loss of life. This article seeks to describe the historical and contemporary context of youth's experiences with the police and present the state of the science linking police contact to poor health. The evidence suggests that police contact is a critical determinant of health for racial and ethnic minority children and that pediatric clinicians, researchers, and policymakers have a role in mitigating the detrimental impact of policing on child health.

Examining the nuance in adolescents' police encounters: Positive, negative, or both?

Youth-police encounters reflect a pivotal point for intervention to improve police-community relations. Data from 454 youths (M = 15.1 years) included brief written descriptions of positive and negative experiences with a police officer and perceptions of police using Likert-scale items. Participating youths described both positive (46%) and negative (60%) experiences with police. Besides decidedly positive experiences, youths also responded to the positive experiences prompt with ambiguous situations (46%) that involved the arrest of the youth or their family (procedural or distributive justice). Examples of ambiguous self-described positive experiences included, "Restraining order," "My dad went to prison," and "When I was arrested in location redacted, the officer was kind and didn't put me in cuffs." Results from regressions indicated youths' perceptions of police were more often associated with the absence of positive experiences than specific positive or negative experiences. Study findings have implications for police trainings and future research on youth-police encounters.

Effects of a Curriculum Addressing Racism on Pediatric Residents' Racial Biases and Empathy.

Background: Racism is a longstanding driver of health inequities. Although medical education is a potential solution to address racism in health care, best practices remain unknown. Objective: We sought to evaluate the impact of participation in a curriculum addressing racism on pediatric residents' racial biases and empathy. Methods: A pre-post survey study was conducted in 2 urban, university-based, midsized pediatric residency programs between July 2019 and June 2020. The curriculum sessions included Self-Reflection on Implicit Bias, Historical Trauma, and Structural Racism. All sessions were paired with empathy and perspective-taking exercises and were conducted in small groups to facilitate reflective discussion. Wilcoxon signed rank tests were used to assess changes in racial bias and empathy. Linear regression was used to assess the effect of resident characteristics on racial bias and empathy. Results: Ninety of 111 residents receiving the curriculum completed pre-surveys (81.1%), and among those, 65 completed post-surveys (72.2%). Among participants with baseline pro-White bias, there was a statistically significant shift (0.46 to 0.36, P=.02) toward no preference. Among participants with a baseline pro-Black bias, there was a statistically significant shift (-0.38 to -0.21, P=.02), toward no preference. Among participants with baseline pro-White explicit bias, there was a statistically significant shift (0.54 to 0.30, P<.001) toward no preference. Among all residents, there was a modest but statistically significant decrease in mean empathy (22.95 to 22.42, P=.03). Conclusions: Participation in a longitudinal discussion-based curriculum addressing racism modestly reduced pediatric residents' racial preferences with minimal effects on empathy scales.

The Intersection of Race, Racism, and Child and Adolescent Health.

There has been an increasing focus on the impact of racism both within pediatrics and throughout society as a whole. This focus has emerged as a result of the current sociopolitical climate in the United States coupled with the recent deaths of Black Americans by law enforcement and the maltreatment of Latina/o immigrants. In 2019, the American Academy of Pediatrics released the landmark policy statement "The Impact of Racism on Child and Adolescent Health," which describes the profound effects of racism on health, its function in perpetuating health disparities, and the potential role of child health professionals in addressing racism as a public health issue. (1) Foundational knowledge regarding race, racism, and their relation to health are not consistently included in standard medical education curricula. This leaves providers, including pediatricians, with varying levels of understanding regarding these concepts. This article seeks to provide an overview of the intersection of race, racism, and child/adolescent health in an effort to reduce knowledge gaps among pediatric providers with the ultimate goal of attenuating racial health disparities among children and adolescents. Please reference the Table for additional resources to reinforce concepts described throughout this article.

Police Exposures and the Health and Well-being of Black Youth in the US: A Systematic Review.

Importance: Black youth in the US experience disproportionate contact with police even when accounting for criminal or delinquent behavior, which some experts say is fueled by racism and discrimination. While the literature supports the link between racism and adverse health outcomes, less is known about the impact of policing on the well-being of Black youth. Objective: To systematically review the literature describing the association between police exposure and health outcomes for Black youth 26 years and younger. Evidence Review: A search of PubMed, Embase, Criminal Justice Abstracts, PsycInfo, and Web of Science was conducted. Eligible studies included original peer-reviewed research published from 1980 to December 2020, with a participant population of Black youth, a focus on police exposure, and health as the outcome. Additional articles were identified by hand-searching reference lists of included studies. Data extraction was performed, followed by critical appraisal of all included studies using a convergent segregated approach in which quantitative and qualitative studies were synthesized separately followed by an overarching synthesis across methods. Findings: A total of 16 quantitative studies including 19 493 participants were included in the review and demonstrated an association between police exposure and adverse mental health, sexual risk behaviors, and substance use. A total of 13 qualitative studies including 461 participants were included in the review, which corroborated and contextualized the quantitative evidence and provided additional health outcomes, such as fear for life or hopelessness. Conclusions and Relevance: Evidence shows that police exposures are associated with adverse health outcomes for Black youth. Clinicians, scientists, public health practitioners, and policy makers can partner with local governments to enact reforms that mitigate the health impact of policing on youth.