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America Becoming: Racial Trends and Their Consequences - Volume II 13 The Health of Minority Children in the Year 2000: The Role of Government Programs in Improving the Health Status of America’s Children Renée R.Jenkins The health status of the children of a society is a reflection of that society’s vision and desire to ensure the safety of its future. Children’s health status makes a statement about the investment a society is willing to make in its youngest members in the face of multiple competing constituencies of its other members. What occurs or does not occur during the early formative years has an impact on adult potential, both physical and cognitive. That potential is also shaped—either restricted or expanded—by environmental, familial, and individual limitations and resources. Thus, the overall health of a child has a direct impact on the probability of that child achieving his or her optimal developmental competency. The challenge before us—improving the health status of all children and reducing racial disparities in their health care—will be informed by understanding both promoting and inhibiting factors related to that goal, which exist in the environment, the family, and the cultural milieu. That challenge should be driven by our need to ensure America’s future. This paper addresses selected health-status indicators and goals from the federal government’s Healthy People 2000 initiative (National Center for Health Statistics, 1996), noting trends, factors that influence the indicators, programs or policies designed to improve health outcomes, and considerations for future research as it relates to minority children. The goals of Healthy People 2000 are widely accepted as nationally critical measures that reflect the effectiveness of preventive health systems in addressing the mental and physical health status of the American people.
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America Becoming: Racial Trends and Their Consequences - Volume II The goals also set national benchmarks for state- and community-level assessments and evaluations. The agenda for health services research often incorporates these goals as outcome measures for health status. Access to health care is directly associated with good health status. Some policies are in place, and others are evolving, to improve access to health care specifically for pregnant women and children. It will be important to examine health outcomes as part of evaluating the programs emanating from these policies. Findings from the evaluations will help researchers adapt the successful models and develop improved models that will take us further in identifying and removing barriers to high-quality health care. As the percentage of minority children in this country grows, the persistence of disparities in attaining optimal health and development will threaten the foundation on which we are building future contributing citizens, workers, and leaders. The question is whether we, as a society, have the will and commitment to invest our resources in reversing negative trends and accelerating positive ones. THE CHANGING CHILD POPULATION AND FAMILY STRUCTURE Although the percentage of the population made up of children younger than age 18 has decreased since 1950, the actual number of children in that age group increased, simply because the numbers increased proportionately for all age groups. In 1950, 31 percent of the U.S. population was children younger than 18 years old, compared to 26 percent in 1990. In 1950, the total number of children in that age group was 47.3 million, compared to 63.6 million in 1990. The Census Bureau projects the percentage of children will plateau by 2010; at that time, the actual number is projected to be 73.6 million. By 2010, the number of Hispanic children is expected to exceed the number of Black children, making Hispanic children, at 18 percent of children, the most populous minority children group (Table 13–1). Asians and Pacific Islanders will be the most rapidly growing population, projected to increase from 2 percent of the population in 1980 to 8 percent in 2020. Since 1960, Americans in all ethnic groups have been having smaller families. The drop was most precipitous for Black families, going from 19 percent of families having four or more children in 1970 to 5 percent in 1994. Whites were more likely than Blacks and Hispanics to live in families with no minor children. From 1950 to 1994, the percentage of children living in female-headed households quadrupled, going from 6 percent to 24 percent. Black children were most affected; more than half lived in single-parent, female-headed households in 1994. Only 28 percent of Hispanic and 18 percent of White children lived in female-headed house-
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America Becoming: Racial Trends and Their Consequences - Volume II TABLE 13–1 Percent Distribution of U.S. Children Under 18 by Race/Ethnicity, 1960 to 2020 1960 1970 1980 1990 1995 2000 2010 2020 Whitea 86 85 74 69 67 64 58 54 Black 13 14 15 15 16 16 17 18 Hispanicb NA NA 9 12 14 15 18 21 Asian American NA NA 2 3 4 5 7 8 Native American NA NA 1 1 1 1 1 1 NA, data not available. aAfter 1980, this Census category is “White, Non-Hispanic.” bHispanics can be either Black or White. SOURCE: For projections 1995–2020: Day, Jennifer Cheeseman, “Population Projections of the United States, by Age, Sex, Race, and Hispanic Origin: 1993–2050,” U.S. Bureau of the Census, Current Population Reports, Series P25–1104, U.S. Government Printing Office, Washington, D.C. 1993. For 1980 and 1990 estimates: “The Challenge of Change: What the 1990 Census Tells Us About Children.” Prepared by the Population Reference Bureau for the Center for the Study of Social Policy. For 1960 and 1970 estimates: Hernandez, Donald J., “Population change, the family environment of children, and statistics on children.” In Trends in the Well-being of America’s Children and Youth, U.S. Department of Health and Human Services, Washington, DC, 1996.
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America Becoming: Racial Trends and Their Consequences - Volume II holds (Figure 13–1). Even though family size decreased, the change from two-parent to single-parent households, with fewer economic resources, increased the likelihood of poverty for those single parents and their children. Childhood poverty and race are intricately interwoven, and young children are most adversely affected by poverty. Even though a higher proportion of minority children are poor, the greatest number of poor children are White, because they are the largest population group. More than 50 percent of children younger than age 6 living in poverty are children of color, but young White children represented 2.5 million poor, young Black children represented 2 million poor, and young Hispanic children represented 1.3 million poor in 1994 (Li and Bennett, 1994). Overall, from 1975 (Figure 13–2A) to 1993 (Figure 13–2B), the percentage of children who lived in households with annual incomes less than 150 percent of the poverty level1 rose for all ethnic groups; however, the most disturbing trend was the flow of children to the bottom rungs of extreme poverty (annual household income less than 50 percent of the poverty level). CHANGES IN INDICATORS OF HEALTH STATUS AND EXPECTATIONS FOR HEALTHY CHILDREN 2000 Observing the progress made toward the Healthy People 2000 goals, it would seem that areas in which interventions have had some success are not the areas most in need of the attention of the health service research community. Infant mortality and child immunizations, the indicators chosen for discussion here, are among those highlighted in the President’s Initiative to end racial disparity in health status for children. Two more indicators, teen births and violent injuries in youth, were selected based on marked discrepancies in the prevalence of these health risk behaviors or conditions between minority youth, particularly Black, and nonminority youth. Infant Mortality Infant mortality has been accepted over the years as an indicator of the well-being of medical and social systems within a country. Although America’s infant mortality rate2 has decreased dramatically since 1960, it 1 The poverty level in 1999 was $16,700 per year for a family of four. 2 Rate of death per 100,000 of children less than 1 year old
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–1 Percent distribution of U.S. children younger than age 18 living with one or two parents in household, by race/ ethnicity: 1940–1994. (A) All children. (B) White children. (C) Black children. (D) Hispanic children. SOURCE: Adapted from Hernandez (1993). Tabulations for 1994 by Child Trends, Inc., from March 1994 Current Population Survey.
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–2A Percentage of children under age 18 in families whose household income is below or near the poverty line, 1975. SOURCE: U.S. Bureau of the Census, Series P-60, No. 188. FIGURE 13–2B Percentage of children under age 18 in families whose household income is below or near the poverty line, 1993. SOURCE: U.S. Bureau of the Census, Series P-60, No. 188. remains one of the country’s most glaring indicators of child health status, displaying a wide disparity between Whites and minorities. Infant mortality rates are quite diverse, however, when one also examines rates for other ethnic minorities, especially when one factors in the components of infant mortality—i.e., neonatal mortality (death within the first 27 days
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America Becoming: Racial Trends and Their Consequences - Volume II of life) and postneonatal mortality (death from day 28 through age 1 year). Hispanics have infant mortality rates very similar to Whites; American Indians and Alaska Natives have rates midway between Whites and Blacks; Asians and Pacific Islanders have the lowest rates. The neonatal mortality rates for American Indians and Alaska Natives approach those of Whites and Hispanics, while postneonatal mortality rates are more similar to those for Blacks. American Indians and Alaska Natives seem particularly vulnerable to sudden infant death syndrome. Among the Hispanic subpopulations, Puerto Rican infants have the highest mortality rate, 8.9 per 1,000. Healthy People 2000 goals for infant mortality for the total population were set at 7 per 1,000. Based on estimated data for 1996 (7.3 per 1,000), it seems likely that target will be met. To date, however, the target for Blacks (11 per 1,000), appears unlikely to be met considering the 1995 statistics were 14.6 per 1,000. The goals set for American Indians and Alaska Natives, 8.5 per 1,000, and Puerto Ricans, 8 per 1,000, are very likely to be met, based on reports of 9 per 1,000 and 8.9 per 1,000, respectively, in 1995. Children’s Immunizations Immunization rates are considered to be a measurable component of the delivery of preventive health services to children and adolescents. Being fully immunized has been demonstrated to correlate highly with other primary-care prevention measures such as screening for anemia, tuberculosis, and lead poisoning (Rodewald et al., 1995). Because this indicator is particularly sensitive for preschool children who are less likely to have received the immunizations as a requirement of school entry, the extent of immunization coverage for children age 19 to 35 months is the standard for comparison between populations. Several major outbreaks of measles occurred from 1989 to 1991 and prompted the Centers for Disease Control and Prevention (CDC) to refocus its efforts on immunizations. Frequent adjustments in the vaccine schedule prevent extended annual comparisons; however, data are available for two sets of annual measures of the combined vaccinations series. The combination series measure is a more stringent measure than the individual vaccine measure. Comparing the 4:3:1 vaccine regimen (four doses of DTP, three doses of poliovirus [Opv], and one dose of measles-mumps-rubella [MMR]) from 1991 to 1993 (Figure 13–3), there were dramatic improvements in the rates of vaccination for Blacks and other minorities as well as all children living below the poverty level. The change for Blacks was an increase from 20.8 percent to 61.8 percent and for poor children, from 23.8 percent to 58.7 percent. In 1994, the hemophilus vac-
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–3 Percent of children 19–35 months who received the combined series immunizations (4:3:1:3*), by race, Hispanic origin, and poverty status. *4:3:1:3, Four doses of DTP, three doses of poliovirus, one dose of measles-mumps-rubella vaccine, and three doses of Haemophilus influenza type b (Hib) vaccine. SOURCE: U.S. Department of Health and Human Services (1996).
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America Becoming: Racial Trends and Their Consequences - Volume II cine was added to the required combination, making it the 4:3:1:3 vaccine regimen (four doses of DTP, three doses of Opv, one dose of MMR, and three doses of hemophilus influenza type b [Hib]). From 1994 to 1996, there continued to be improvement in the rates (Figure 13–4), up to a total of 74 percent for Black children and 78 percent for Asian and Pacific Islander children (a 23 percent increase). American Indians and Alaska Natives had the highest completion rates of all the minority groups measured. Poor children reached a maximum of 69 percent. The Healthy People 2000 goal is 90 percent for the basic immunization series. If the annual incremental gains continue at their current pace, Asian and Pacific Islander children may reach the target; however, other ethnic groups, including Whites and poor children, would have to accelerate their gains significantly to reach the goal. Teen Births Teen births have been linked to increased vulnerability to adverse social, economic, and psychosocial risks for both the mothers and their children. Teen birth rates reached an all-time low in the mid-1980s, only to climb and peak again in 1991 (Figure 13–5). The rates have dropped since 1991, but they have yet to reach their nadir of the mid-1980s. Although the rates dropped most precipitously for Black teens (21 percent from 1991 to 1996) compared to the 5- to 12-percent drop for other groups, there is still a wide disparity between Black, Hispanic, and American Indian and Alaska Native girls compared to White and Asian and Pacific Islander girls. Healthy People 2000 goals for teens are framed in terms of teen pregnancies rather than teen births. “Teen pregnancies” is a combination of the birth rate along with estimates of induced abortions and fetal losses. For example, although the teen birth rate in 1994 was 58.9 per 1,000, the pregnancy rate was 108 per 1,000 (Ventura et al., 1998). The goals for teen pregnancy were set at rates that are extremely unlikely to be met, given that the birth rate alone approximates the pregnancy targets of 50 per 1,000 for the total population and 120 and 105 per 1,000 set for Blacks and Hispanic teens, respectively. It appears as though those targeted goals were very unrealistic; theory-driven estimates should be recalculated and reconsidered for the 2010 projections. Violent Injuries From 1983 to 1993, the homicide-with-the-use-of-firearms rate more than tripled, from 5 to 18 per 100,000. Since 1993, the rates of fatal and nonfatal firearm injuries declined; but from 1993 to 1995, the estimated case-fatality rate increased among males age 15 to 24 years, suggesting
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–4 Percent of children 19–35 months who received the combined series immunizations (4:3:1*), by race and poverty status. *4:3:1, Four doses of DTP, three doses of poliovirus, one dose of measles-mumps-rubella vaccine. SOURCE: U.S. Department of Health and Human Services (1996).
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–5 Birth rate for teenagers 15–19 years by race and Hispanic origin: United States. SOURCE: National Center for Health Statistics. that the use of higher-powered, semiautomatic handguns increased the lethality of firearm injuries. Males are much more likely to be represented in fatal and nonfatal firearm injuries; however, compared to women in other age groups, 15- to 24-year-old women are the age group with the highest percentage of injuries. Black males age 15 to 19 years old are twice as likely as Hispanic males and six times more likely than White non-Hispanic males to be killed with a firearm (Figure 13–6).
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America Becoming: Racial Trends and Their Consequences - Volume II The Youth Risk Behavior Surveillance System (Kahn et al., 1996) reports that in 1995, 20 percent of students (31 percent male and 8 percent female) carried a weapon, such as a gun, knife, or club, within the 30 days preceding a survey. Compared to the baseline survey done in 1991, however, weapon carrying had decreased. The survey also showed that whereas 39 percent of students reported having been in a fight in the past year in 1993, rates for this indicator also declined, from 137 per 100 students per 12 months in 1993 to 128 in 1995. Black and Hispanic youth were more likely to carry a weapon, be involved in fights, and be victimized by others (Anglin, 1997). The Healthy People 2000 goals for violence reduction are highly likely to be met in some areas but not in others. The overall goal of a homicide mortality rate of 7.2 per 100,000 is very much on its way to being met, with an unadjusted rate of 7.9 reported for 1996. The target rate of 42.5 per 100,000 for Hispanic males age 15 to 34 is also likely to be met considering the 1996 rate was 48.9, balanced by a 31.2 rate for 25 to 34 year olds. By comparison, the target rate of 72.4 for Black males seems fairly distant from the 1996 report of 123.1 for 15 to 24 year olds and 89.5 for 25 to 34 year olds (U.S. Department of Health and Human Services, 1991; National Center for Health Statistics, 1998). The risk-reduction objectives for physical fighting and weapon carrying for 14 to 17 year olds are set at 20 percent lower than the 1991 baseline survey. By the first follow up in 1995, weapon-carrying reports for the total population and for Blacks had reached or surpassed the goal. The percentages for Hispanics had decreased but lagged behind in the percentage reduction necessary to meet the goal. Findings showed less success in reaching targeted goals for physical fighting, but the trend is still toward improvement for the total population and for Blacks. Hispanic youth reported an increase in physical fighting from 41.3 percent in 1991 to 47.9 percent in 1995. Rates for these behaviors vary by geographic area; therefore, comparisons from survey to survey must take into account any variations in participating sites when estimating changes over time. Summary The likelihood of the Healthy People 2000 goals, as stated above, being met varies considerably by goal and ethnic group. The overall infant mortality goal will probably be met, as will the targets for Puerto Rican and American Indian and Alaska Native infants. The target is unlikely to be met for Black infants, however. Immunization goals will be met for Asian and Pacific Islander children but are unlikely to be met for other groups. Although the decreasing number of births (and abortions)
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–6 Injury mortality rates among adolescents ages 15–19 by gender, race, Hispanic origin, and type of injury, 1994–1995. SOURCE: Indicators of Children’s Well-being: Health, 1997.
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America Becoming: Racial Trends and Their Consequences - Volume II is encouraging, the teen pregnancy reduction goals are completely unrealistic. Violent deaths, specifically overall homicide rates, will likely be reduced to the overall target goals; and it is likely the goals for Hispanic males will also be met. It is highly unlikely that the goal set for the Black male population will be achieved. Weapon carrying among all teens decreased significantly and target goals will likely be met; however, reports of physical fighting for Hispanic male adolescents have increased. If intervention strategies designed to improve outcomes that fall short of the Healthy People 2000 goals are to be effective, they must focus on factors unique to the specific indicators and populations as well as factors that are similar for several indicators and populations across family, community, and health system variables. STRATEGIES ADDRESSING THE DISPARITY GAP Infant Mortality The public health community has struggled over the past decade to reduce infant mortality, meeting some success in reducing the rate overall, but frustrated by persistently high rates in comparison to other industrialized nations and by the rates in minority populations and in large urban areas. The Healthy Start Initiative is the most recent federal program directed toward reducing infant mortality at the community level. During the initial phase of the program, which began in 1991, the Health Resources Service Administration funded five-year demonstration projects in 15 communities with the ambitious goal of reducing infant mortality rates by 50 percent within the five-year project period. Strategies were to be unique to each community, and the issue of medical intervention was to be addressed as were issues related to poverty, inadequate community services, and educational factors. The community sites were expected to demonstrate innovation, community commitment and involvement, increased access to care, service integration, and personal responsibility. Additional “special projects” and 41 new community sites have been funded since 1997 (U.S. General Accounting Office, 1998). Minority groups were well represented in the targeted communities; the original demonstration grants included two sites that served American Indian and Alaska Native mothers. Evaluation of the demonstration projects is still under way; however, issues related to ethnic identity have arisen that may influence the interpretation of the evaluation data. Mothers who note their baby’s race for birth records may identify race differently than hospital personnel who categorize the race or ethnicity of babies who die; hence, vital record identifiers may not match. A special U.S. Department of Health and
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America Becoming: Racial Trends and Their Consequences - Volume II Human Services Secretarial Task Force on Racial Disparities is addressing this issue, as well as others, in a focused effort to have Healthy Start evaluation data contribute to successful strategies to reduce racial disparities. Children’s Immunization Access is one of the key issues being addressed by Healthy Start and other initiatives to improve infant health, such as the State Child Health Insurance Program (SCHIP). Adult as well as child health data show economic barriers to be the primary impediments blocking poor, minority patients from access to health care, particularly nonurgent, preventive care (Andrulis, 1998; Newacheck et al., 1996). Poverty, minority status, and lack of health insurance exerted independent effects on access to and use of primary care. Poor children, minority children, and uninsured children were twice as likely as children in the mainstream to lack a usual source of care, to wait longer at the site of care, and to receive fewer physician services after controlling for health status (Newacheck et al., 1996). Although SCHIP is in the early stages of national implementation, many states had already begun special programs for uninsured children and are able to demonstrate successful outcomes in many of the areas of deficiency noted in the baseline studies. One such model, in western Pennsylvania, reported that after 12 months of their program, 99 percent of the children had a regular source of care and 85 percent had a regular dentist, compared to 89 percent and 60 percent, respectively, at baseline; reports of unmet need or delayed care in the past 6 months were reduced from 57 percent to 16 percent at 12 months. During this same period emergency department visits decreased from 22 percent to 17 percent, suggesting more appropriate use of services by the newly insured. Although these data are reported for a predominantly White population (94.4 percent), they are encouraging and provide a methodology for evaluation of strategies in other communities with more ethnically diverse populations (Lave et al., 1998). The usefulness of these data is limited because it is too soon to link them to immunization rates and other health-screening procedures. The challenge will be for those implementing SCHIP in the different states to provide data via commonly accepted indicator measures. Teen Births Decreases in the teen birth rate are attributed to five major factors: (1) a greater emphasis on delaying sexual activity; (2) more conservative
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America Becoming: Racial Trends and Their Consequences - Volume II attitudes among teenagers about casual sex and out-of-wedlock childbearing; (3) fear of sexually transmitted diseases, especially HIV and AIDS; (4) increased use of long-acting contraceptive methods; and (5) a strong national economy with better job prospects for young people (Donovan, 1998). The program strategies have varied widely from concentrating on delaying sexual activity in young teens through comprehensive approaches to addressing academic skills, social skills, and contraceptive knowledge, to offering family planning and counseling services in school settings or adjacent to schools. Violent Injury The CDC has led the major research effort in community interventions for violence prevention programs. The strategy for selecting potentially successful interventions has been as follows: Interventions must encompass individual and social factors. Violent behaviors are influenced not only by characteristics of individuals, but also by—moving out from the individual—characteristics of families, such as cohesion and parent practices; characteristics of peers, such as delinquent behaviors; characteristics of schools, such as teacher practices and school atmosphere; characteristics of community organization, such as the frequency and type of youth activities; and characteristics of the larger society, such as economic opportunity, misuse of firearms, or media exposure. Violence-prevention efforts to date have emphasized individually oriented strategies, directed toward students in school or patients in clinical settings. These approaches should be continued, but need to be complemented by activities designed to modify exposures at the family, peer, community, and society level (Satcher et al., 1996, v-vi). RESEARCH CHALLENGES FOR REACHING 2010 GOALS Broad Institutional and System Issues Reducing the health disparity gap can be addressed at national, community, and individual levels. Health services research models can take into account policy as well as program impact within and across settings—e.g., the impact of changes in eligibility for a state Medicaid program on immunization rates. Using national data, research can be conducted on how policy changes that affect a family’s financial resources in turn affect access to quality health care, because national data provide the complexity of detail necessary for ethnic subgroup analysis—i.e., the full demographic variation that is not possible with smaller population studies.
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America Becoming: Racial Trends and Their Consequences - Volume II Community-based studies, particularly research interventions, use innovative models to involve communities in creating the solutions to their problems. These interventions often employ community residents as project staff. These smaller studies can collect more individualized health and laboratory data. This level of data collection is preferable for examining relationships between biochemical markers and behavioral measures, such as the work being done that associates (a-feto protein with preterm delivery and stress and support issues. Specific Applications Although limited, the set of program interventions offered above as examples demonstrates the approaches that enhance successful strategies—the kind that move us further toward reducing racial disparities in child and adolescent health status. When the data set allows, specific ethnic subgroup analysis is preferable in Hispanic and Asian and Pacific Islander populations, given the differing baseline and outcome data that may emerge in such subpopulations. Poverty has been so inextricably linked to minority groups, because of the disproportionate representation of minority families with annual incomes below the poverty level, that intragroup studies with more middle-income representation should be considered when “teasing” out effects of financial as well as nonfinancial barriers to access and changes in health behavior. It appears as though the most recent intervention programs have been “reawakened” to the importance of enlisting the community as collaborators in seeking solutions to health problems prevalent in their midst. The Healthy Start as well as the CDC Violence Prevention programs have taken on this approach. The impact of racism and discrimination in the health-care delivery system as sources of stress and adverse health experiences has not been successfully addressed. Ethnic identity has begun to appear as a variable in research addressing youth violence. As more minority researchers, with their own personal experiences in these issues, become part of the investigator cadre, one hopes that the issues of stress and racism will be included more consistently. On the other end of the spectrum, more research on positive constructs, such as “social capital” (personal relations and network of relations—e.g., church), which identifies supportive elements for resilient individuals and families, is essential to formulating more proactive, as compared to corrective, interventions (Runyan et. al, 1998). A model in which the contextual issues of racism and discrimination were included was recently introduced by a multidisciplinary group of investigators looking at developmental competencies in Black and His-
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America Becoming: Racial Trends and Their Consequences - Volume II FIGURE 13–7 Integrative model for the study of developmental competencies in minority children. SOURCE: García-Coll et al., 1996. Reprinted with permission from the Society for Research in Child Development, Ann Arbor, Mich.
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America Becoming: Racial Trends and Their Consequences - Volume II panic children (García-Coll et al., 1996). The model, though complex at first sight, does allow one the overall contextual setting for contributory factors in the developmental process. It may be useful for investigators— those seeking to move to more population-specific dynamics—to understand and operationalize noneconomic residuals that remain, should the public health community be successful in removing the economic barriers to health care. CONCLUSION Having a set of agreed upon goals for health status that are tracked at national and state levels creates an excellent opportunity for health services research. The impact of health policies at state and national levels can create the context for the examination of a myriad of indicators used to measure many of the adverse trends in these goals that disproportionately affect minority children and youth (Figure 13–7). The four addressed in this paper—infant mortality, childhood immunization, teen pregnancy, and youth violence—are among the most glaring at the national level, but others may be more evident in differing communities. The work that continues to be done for the next iteration of Healthy People, the goals for 2010, is to set forth a process that promotes wide dissemination in a manner that allows researchers and policy makers to help shape these new targets. The challenge to the community of researchers is to use those goals in a focused effort to reduce racial disparities and to benefit the most needy of the population. REFERENCES Andrulis, D. 1998 Access to care is the centerpiece in the elimination of socioeconomic disparities in health . Annals of Internal Medicine 129(5):412–416. Anglin, T. 1997 The medical clinician’s roles in preventing adolescent involvement in violence. Adolescent Medicine: State of the Art Reviews 8(3):501–515. Donovan, P. 1998 Falling teen pregnancy, birthrates: What’s behind the declines? Guttmacher Report on Public Policy (October). García-Coll, C, G.Lamberty, R.Jenkins, H.McAdoo, K.Crnic, B.Wasik, and H.Vasquez 1996 An integrative model for the study of developmental competencies in minority children. Child Development 67(5):1891–1914. Hernandez, Donald J. 1993 America’s Children, Resources for Family, Government and the Economy. New York: Russell Sage Foundation. 1996 Population change, the family environment of children, and statistics on children. In Trends in the Well-Being of America’s Children and Youth, U.S. Department of Health and Human Services, Washington, D.C.
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America Becoming: Racial Trends and Their Consequences - Volume II Kahn L, C.Warren, W.Harris, J.Collins, B.Williams, J.Ross, and L.Kolbe 1996 Youth risk behavior surveillance—United States, 1995. MMWR 45(SS04):1–83. Lave, J., C.Keane, C.Lin, E.Ricci, G.Amersbach, and C.LaVallee 1998 Impact of a children’s health insurance program on newly enrolled children. Journal of the American Medical Association 279(22):1820–1825. Li, J., and N.Bennett 1994 Young Children in Poverty: A Statistical Update. New York: National Center for Children in Poverty. National Center for Health Statistics (NCHS) 1996 Healthy People 2000 Review, 1995–1996. Hyattsville, Md.: U.S. Public Health Service. 1998 Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Hyattsville, Md.: U.S. Public Health Service. Newacheck, P., D.Hughes, and J.Stoddard 1996 Children’s access to primary care: Differences by race, income, and insurance status. Pediatrics 97(1):26–32. Rodewald, L., P.Szilagyi, T.Shiuh, S.Humiston, C.LeBaron, and C.Hall 1995 Is underimmunization a marker for insufficient utilization of preventive and primary care? Archives of Pediatric & Adolescent Medicine 149:393–397. Runyan, D., W.Hunter, R.Socolar, L.Amaya-Jackson, D.English, J.Landsverk, H. Dubowitz, D.Browne, S.Bangdiwala, and R.Mathew 1998 Children who prosper in unfavorable environments: The relationship to social capital. Pediatrics 101(1):12–18. Satcher D., K.Powell, J.Mercy, and M.Rosenberg 1996 Opening commentary: Violence prevention is as American as apple pie. American Journal of Preventive Medicine 12(5):v. U.S. Department of Health and Human Services 1991 Healthy Children 2000: National Health Promotion and Disease Prevention Objectives Related to Mother, Infants, Children, Adolescents, and Youth. National Maternal and Child Health Clearinghouse. 1996 Trends in the Well-Being of America’s Children and Youth. Washington, D.C. U.S. General Accounting Office (GAO) 1998 Report to Congressional Requesters, Healthy Start—Preliminary Results from National Evaluation Are Not Conclusive: Preliminary Evaluation of Healthy Start. June. Ventura, S., S.Curtin, and T.Mathews 1998 Teenage Births in the United States: National and State Trends, 1990–1996. National Vital Statistics System. Hyattsville, Md.: National Center for Health Statistics.
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