Closing the Opportunity Gap for Young Children (2023) / Chapter Skim
Currently Skimming:
4 Opportunity Gaps in the Physical Health and Health Care Experienced by Young Children and Their Parents
4 Opportunity Gaps in the Physical Health and Health Care Experienced by Young Children and Their Parents
Pages 205-262
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From page 205... ...
While differences in health care access and quality explain some of these disparities, they are strongly rooted in structural racism and discrimination, as well as underinvestment in economically disadvantaged urban and rural areas (Oberg et al., 2016)
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. The second section of this chapter reviews existing research on potential solutions to some of the drivers of the opportunity gaps in physical health and health care.
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Research is clear that a pregnant person's access to health insurance can influence the use and timing of prenatal care; that adequate prenatal care is associated with healthier birth outcomes, such as a longer period of gestation and healthier birthweight (Creanga et 1The committee uses the terms "woman" and "mother" in this report; however, we recognize that the terms "pregnant woman," "woman," "mother," and "maternal" may not reflect how some pregnant individuals or others seeking reproductive health care may identify.
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. These early opportunity gaps can widen opportunity gaps and outcomes over the life course.
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In these nonexpansion states, no childless adults are eligible for Medicaid, and the income eligibility threshold for parents varies from a low of 17% of the FPL in Texas to 100% of the FPL in Wisconsin, leaving millions of parents and prospective parents without access to health insurance, a resource that promotes healthier birth outcomes and health across the lifespan. The percentage of women who lack health insurance is much higher in states that have not expanded Medicaid.
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. Maternal Access to Adequate Prenatal Care Related to access to health insurance is access to quality prenatal care, which in turn is linked to healthier birth outcomes and better health for the mother.
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(See Chapter 6 for a more detailed discussion of opportunity gaps in social-emotional health and well-being.)
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. Adverse birth outcomes reflect the trauma resulting from discrimination and racism that many Black women have experienced across their life course, as well as their disproportionately lower access to financial security (Alhusen et al., 2016)
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. The medical home is significantly associated with positive child health outcomes regardless of household income.
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. Routine health care -- in particular, well-child visits -- is essential for child health and development and can be an important component of lifelong health.
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. Pediatric health care visits have traditionally focused on regular immunizations, assessment of growth and developmental milestones, and anticipatory guidance for parents on child development and preventive care to reduce risk for injuries and promote social-emotional learning.
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. The National Academy of Medicine report Vibrant and Healthy Kids provides an extensive review of stress, traumatic stress, adverse childhood experience, and positive buffers.
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Structural or institutional racism results in decreased access to health care and fewer resources for education, often leading to lower health literacy and fewer health care providers of color. Despite progress in treating and preventing many diseases overall, health disparities continue to exist across different groups, with Black individuals experiencing higher rates of diabetes, obesity, asthma, and hypertension compared with their White counterparts (National Center for Health Statistics [NCHS]
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From page 218... ...
also are critical for child development. Similarly, teachers and other adult mentors in educational settings can play important roles in promoting child health.
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It is plausible that adultification informs one form of implicit bias that is associated with such disparate treatment and with physical health outcomes. Implicit racial bias toward Black children has been demonstrated at levels similar to those directed at Black adults (Johnson et al., 2017)
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Achieving health equity will therefore require addressing institutional, structural, and systemic racism in health care and public health, and race-based medicine is one area in which systemic racism manifests. It is also worth noting that, while pediatricians have often served as lead clinician in the pediatric medical home, a team-based approach to child health has emerged by which primary care is reconfigured to address access issues.
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From page 221... ...
. Implicit bias is thought to influence administrative decisions on insurance plans accepted, neighborhoods for establishing offices, and selection and inclusion of diverse students in medical education and training and among faculty (Ansell & McDonald, 2015)
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More equitable and antiracist care practices could be supported if providers had a deeper understanding of structural and institutional racism and interpersonal discrimination and their impacts on health, clinical encounters, and conditions. To date, however, literature conceptualizing structural racism has not been adequately integrated into medical education, and the majority of empirical studies of racism have focused on interpersonal discrimination rather than structural racism (Bailey et al., 2017)
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. Medical students who hold such false beliefs were found to be more likely to rate pain lower and make less accurate treatment recommendations for Black versus White patients (Hoffman et al., 2016)
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In May 2022, it released a policy statement, "Eliminating Race-Based Medicine," that calls for scrutiny and revision of the suite of clinical guidelines, algorithms, educational materials, textbooks, and literature used to guide clinical practice and for medical education (Wright et al., 2022)
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. Existing programs and tax credit policies play an important role in improving nutrition for the poorest children, and recent extensions to these programs may help achieve significant progress toward reducing child hunger and poor nutrition.
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. Safe and Healthy Environments As discussed previously, young children exist within the contexts of their families and neighborhoods, including the places where they live, learn, and play, and these environments need to be safe and healthy if children are to achieve optimal physical health, growth, and development.
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. After reviewing some methodological considerations regarding the association between neighborhood and child health, this section looks at two specific aspects of neighborhoods thought to be linked most directly with young children's physical health: freedom from environmental contaminants and safety and freedom from violence.
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. Unfortunately, few of these quasi-experimental studies have focused on child health, and the circumstances underlying the natural experiment, including those just cited, are often "unnatural," hinging on quasi-random variation generated by natural disasters or policies that typically are not generalizable (Hamad, 2020)
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From page 229... ...
Environmental contaminants have repeatedly been found to be associated with poor health throughout the life course, and the prenatal and early childhood periods represent particularly sensitive developmental windows in which individuals may be especially vulnerable to their effects. Young children may be exposed to thousands of potential contaminants, including through the air they breathe, the water they drink and use, the food they eat, and the consumer products with which they come into contact (Giudice, Woodruff, & Conry, 2017)
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From page 230... ...
Other environmental contaminants Numerous other environmental contaminants have been linked to adverse health outcomes at birth and in early childhood. Chemicals from heavy metals and pesticides to carbon monoxide and ozone are thought to affect neurological development and BOX 4-2 Policy Lessons: Lead Exposure and Academic Performance Beginning in the 1970s, the state of Massachusetts established a Childhood Lead Poisoning Prevention Program making it mandatory to screen children under 6 years of age, provide medical and environmental services to families affected by lead exposure, and implement policies to eliminate potential sources of such exposure (Commonwealth of Massachusetts, 2022)
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From page 231... ...
Therefore, these contaminants may have both immediate impacts on health and wellness and long-term effects on chronic disease, educational attainment and achievement, and mortality. Opportunity gaps related to environmental contaminants As the evidence reported above demonstrates, children experience differing levels of exposure to environmental contaminants, such as lead and those that place them at risk of asthma.
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. The primary reason for differential exposures to environmental contaminants is proximity to sources of pollutants, such as traffic and roadways, industrial facilities, power plants, and natural gas wells, that repeatedly have been associated with worse health outcomes for children, including adverse birth outcomes and asthma in particular (Ahmad et al., 2001; Hopenhayn et al., 2003; Tsai et al., 2004; Salam, Islam, & Gilliland, 2008; Clark et al., 2010; Pénard-Morand et al., 2010; Currie & Walker, 2011; Padula et al., 2012; Miranda et al., 2013; Ha et al., 2015; Woodward, Finch, & Morgan, 2015; Casey et al., 2016; Harris et al., 2016; Alexander & Currie, 2017; Fleisch et al., 2017)
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. The total lifetime economic cost associated with child maltreatment in terms of worse outcomes, lower educational
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. According to a CDC report based on data from 2000–2009, American Indian/Alaska Native children had the highest death rate from injuries at 30.4 per 100,000 in 2000 and 23.8 per 100,000 in 2009 -- nearly double the rates among Black children (16.2 and 12.8, respectively)
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From page 235... ...
Opportunity gaps related to safety and exposure to violence Several factors may explain the above disparities in young children's exposure to violence; they include individual, family, and place-based risk factors. On an individual level, babies under 1 year old experience higher rates of injuries and maltreatment (CDC, 2014, 2021)
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Black children and teens are four times more likely than their White peers to die from gun violence. FIGURE 4-1 Leading causes of death among children and adolescents in the United States, 1999–2020.
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. ADDRESSING OPPORTUNITY GAPS IN PHYSICAL HEALTH AND HEALTH CARE Opportunity gaps in the physical health and health care of young children can be addressed through efforts focused on poverty reduction, access to pediatric and family health care, antiracism and dismantling of race-based medicine, screening for social influences on health, alternative models for delivering health care, and safe and violence-free environments.
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From page 238... ...
Among those federal governmental programs specifically designed to address poverty are the earned income tax credit, the child tax credit, and the Supplemental Nutrition Assistance Program, which provide cash or inkind transfers to low-income families, and all of which have been shown to reduce poverty and improve child health outcomes. The temporary expansion of the child tax credit in response to the COVID-19 pandemic had a significant impact on poverty alleviation, reducing child poverty by about 30% and decreasing food insufficiency, with implications for the well-being of many of the nation's most vulnerable children.
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Race-based medicine is a clear driver of opportunity gaps in medical treatment and care. Antiracism is an active practice that involves learning about how racism is constructed, operationalized, and perpetuated and working to dismantle those systems.
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There remains a critical need for research comparing models for delivering primary care and examining their impact on racial/ethnic and socioeconomic inequities in preventive care utilization and health outcomes. Safe and Violence-free Environments Given the numerous risk factors that place children at higher risk of exposure to unsafe environments, individual and family interventions are unlikely to be sufficient; multilevel societal interventions and policies are needed.
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From page 241... ...
In all of these cases, however, notable disparities exist by race/ethnicity, income, rural versus urban residence, and immigration status. In the prenatal period, adverse outcomes experienced by children and birthing people are often due to preventable pregnancy and birth complications, inadequate access to health insurance, and suboptimal prenatal care.
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Children of color and those from lower-income households are more likely to experience these opportunity gaps. The COVID-19 pandemic and related policies, such as school closures, exacerbated these disparities, because of both the disproportionate burden of disease experienced by low-income communities and people of color and the further limitations placed on access to key material and psychosocial resources among marginalized groups.
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. The child opportunity gap: Inequities in child opportunity within metros.
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. Income disparities in the association of the medical home with child health.
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. Preterm birth and later retinal detachment: A population-based cohort study of more than 3 million children and young adults.
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. Unconventional natural gas development and birth outcomes in Pennsylvania, USA.
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. Preterm birth and risk of chronic kidney disease from childhood into mid-adulthood: National cohort study.
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. Effects of preterm birth and fetal growth retardation on cardio vascular risk factors in young adulthood.
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. Implicit bias in healthcare professionals: A systematic review.
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. Accelerating child health care transforma tion: Key opportunities for improving pediatric care.
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. Poverty and child development: A longitudinal study of the impact of the earned income tax credit.
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National Vital Statistics Reports, 68(6)
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. Associations between maternal experiences of racism and early child health and development: Findings from the UK Millennium Cohort Study.
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. Association of state-level earned income tax credits with rates of reported child maltreatment, 2004–2017.
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. Neurologic and developmen tal disability at six years of age after extremely preterm birth.
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pdf National Institute of Child Health and Human Development.
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. Child health disparities in the 21st century.
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. Effects of preterm birth and fetal growth retarda tion on life-course cardiovascular risk factors among schoolchildren from Colombia: The Fuprecol study.
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. An analysis of group versus individual child health supervi sion.
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. Adverse effects of maternal lead levels on birth outcomes in the ALSPAC study: A prospective birth cohort study.
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. Long-term classroom functioning and its association with neuropsychologi cal and academic performance following traumatic brain injury during early childhood.
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. Disparity in risk factor severity for early child hood blood lead among predominantly African-American black children: The 1999 to 2010 US NHANES.
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