SAUDE DA CRIANÇA LATINA

8/2/2019 SAUDE DA CRIANA LATINA

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SPECIAL COMMUNICATION

The Health of Latino ChildrenUrgent Priorities, Unanswered Questions,and a Research AgendaGlenn Flores, MD

Elena Fuentes-Afflick, MD, MPH

Oxiris Barbot, MD

Olivia Carter-Pokras, PhD

Luz Claudio, PhD

Marielena Lara, MD, MPH

Jennie A. McLaurin, MD, MPH

Lee Pachter, DO

Francisco Ramos Gomez, DDS, MPH

Fernando Mendoza, MD, MPH

R. Burciaga Valdez, PhD

Antonia M. Villarruel, PhD

Ruth E. Zambrana, PhD

Robert Greenberg, MD

Michael Weitzman, MD

LATINOS ARE THE LARGEST MINOR-ity group of children (11.6 mil-lion) in the United States,1 com-prising 16% of the population

younger than 18 years.1 In California, themost populous state, Latinos surpassedwhites as the states largest racial/ethnicgroup of children in 2000.2 By 2010, ap-proximately half of all California chil-dren will be Latino, and they will out-number white children by 1.9 million;in 2030, 57% of California children (9.2

million)will be Latino, andthey will out-number white children by 5.3 million.2

Given the tremendous growth of thispopulation, pediatricians and otherhealth care practitioners, child health re-searchers, and child health policy mak-ers are increasingly likely to encounterLatino children in their practices, studypopulations, and legislative agendas.

Author Affiliations: Department of Pediatrics, Bos-ton UniversitySchools of Medicine and Public Health,Boston Medical Center, Boston, Mass,and Center forthe Advancement of Urban Children, Department ofPediatrics, Medical College of Wisconsin, Milwaukee(Dr Flores); Departmentof Pediatrics,Universityof Cali-fornia, SanFrancisco, School of Medicine(Dr Fuentes-Afflick);National Hispanic Medical Association and So-ros Advocacy Fellow, Washington, DC (Dr Barbot);Officeof Minority Health, Department of Healthand

HumanServices, Rockville, Md (Dr Carter-Pokras); De-partment of Community Medicine, MountSinai Schoolof Medicine, New York, NY (Dr Claudio); Depart-mentof Pediatrics, UCLA School of Medicine, Los An-geles, Calif (Dr Lara);Migrant CliniciansNetwork, Aus-tin,Tex (Dr McLaurin); Departments of PediatricsandAnthropology, University of Connecticut School ofMedicine, Saint Francis Hospital and Medical Center,Hartford (Dr Pachter); Department of Health Ser-vices Research, University of California, San Fran-cisco, School of Dentistry (Dr Gomez); Department ofPediatrics,Stanford University School of Medicine, Palo

Alto, Calif (DrMendoza); Schoolof PublicHealth, MCPHahnemann University, Philadelphia, Pa, and RANDHealthScience Program, Santa Monica, Calif (DrVal-dez); Division of Health Promotion and Risk Reduc-tionPrograms, School of Nursing,University of Michi-gan,Ann Arbor(Dr Villarruel);Department of WomensStudies, Universityof Maryland, CollegePark(Dr Zam-brana); Department of Pediatrics, University of NewMexico School of Medicine, Albuquerque (Dr Green-berg);and Centerfor Child HealthResearch andUni-

versity of Rochester School of Medicine, Rochester,NY (Dr Weitzman). Authors are the members of theLatino Consortium of the American Academy of Pe-diatrics Center for Child Health Research.

AfterJuly30, 2002, Dr Floreswill bewiththe Cen-ter for the Advancement of Urban Children, Depart-ment of Pediatrics, Medical College of Wisconsin,MACC Fund Research Center, Milwaukee.Corresponding Author and Reprints: Glenn Flores,MD, Division of General Pediatrics, Boston MedicalCenter, 91 E Concord St, Maternity419, Boston, MA02118 (e-mail: [email protected]).

Latinosrecentlybecame the largest racial/ethnicminoritygroupof US children.

TheLatino Consortium of theAmericanAcademy of Pediatrics Centerfor Child

Health Research, consisting of 13 expert panelists, identified the most impor-

tant urgent priorities and unanswered questions in Latino child health. Con-

clusions were drawn when consensus was reached among members, with re-

finement through multiple iterations. A consensus statement with supportingreferences was drafted and revised. This article summarizes the key issues, in-

cluding lack of validated research instruments, frequent unjustified exclusion

from studies, and failure to analyze data by pertinent subgroups. Latino chil-

dren are at high risk for behavioral and developmental disorders, and there are

many unanswered questions about their mental health needs and use of ser-

vices.The prevalence of dental cariesis disproportionatelyhigherforLatinochil-

dren, but the reasons for this disparity are unclear. Culture and language can

profoundlyaffect Latino childrenshealth, but not enoughcultural competency

training of health care professionals and provision of linguistically appropri-

ate care occur. Latinos are underrepresented at every level of the health care

professions. Latino children are at high risk for school dropout, environmental

hazards,obesity, diabetesmellitus, asthma, lackof health insurance,nonfinan-

cial barriers to health care access, and impaired quality of care, but many key

questionsin these areasremainunanswered. This article suggests areasinwhich

more researchisneededand ways toimprove researchandcareof Latinochildren.

JAMA. 2002;288:82-90 www.jama.com

82 JAMA, July 3, 2002Vol 288, No. 1 (Reprinted) 2002 American Medical Association. All rights reserved.

at Coordenacao de Aperfeicoamento de Pessoal de Nivel on January 9, 2012jama.ama-assn.orgDownloaded from
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Latino children are a model popula-tion for evaluating effective approachesto improving the health of underservedand high-risk populations because theyexperience a disproportionateburdenofhealth risk factors, morbidity, subopti-

malhealth status, underuse ofhealthser-vices,impaired accessto care, andhealthdisparities.3 For example, Puerto Ricanchildren have the highest prevalence ofactiveasthma(11%),exceedingby fartheprevalence for blacks (6%) and whites(3%).4 Latino children are at signifi-cantly greater risk than whites of beinghospitalized for or dying from injuries5

and are13 times more likely than whitesto be infected with tuberculosis.6 Evenafter adjustment for family income andparental education, Latino children aresignificantly more likely than whites to

have suboptimal health status, spendmore days in bed for illness, and makefewer physician visits.7 Latino childrenface numerous barriers to healthcare, in-cluding language problems, cultural is-sues, and lack of health insurance.8

Health disparitiesfor Latino children in-clude a lowerlikelihood ofvisionscreen-ing,9 receiving prescriptions,10 being ad-equately medicated for pain,11 andreceiving high-quality care for asthma12

and gastroenteritis.13

The mission of the Latino Consor-

tium of the American Academy of Pe-diatrics Center for Child Health Re-search (CCHR) is to define the criticalresearch and policy issues in Latinochildrens health.

METHODS

The Latino Consortium, sponsored andpartially supported by the AmericanAcademy of Pediatrics, consists of 13expert panelists selected to provideskills in multiple disciplines relevant tochild health and includes pediatri-

cians, health service researchers, a di-rector of research at the Office of Mi-nority Health, an academic dentist, ananthropologist, an academic nurse, adean of a school of public health, andan environmental health expert.

The methods used in developing thisassessment were as follows: first, eachmember was asked to identify the most

important issue facing Latino childrenandyouth, without repeating any issue.All topics identified wereincluded; con-clusionswereagreed onby reaching con-sensus. Second, multiple iterations en-abled topic refinement and clarification.

A preliminary consensusstatement wasdrafted after the initial group assess-ment of priorities andunanswered ques-tions and was then reviewed 3 times byall consortium members, and sugges-tions were incorporated in each revi-sion. Third, supporting references werereviewed andincluded,with therequire-ment that each topic identified as an ur-gent priority or unanswered question bevalidated or supported by publishedstudies. Fourth, the manuscript was re-distributed, discussed, and reviewedtwice by each consortium member after

peer review by THE JOURNAL.Latino here denotes all US persons

whose origins can be tracedto theSpan-ish-speaking regions of Latin America,including the Caribbean, Mexico, Cen-tral America, and South America. His-panic places narrow and excessive em-phasis on the European influence ofSpanish colonialism anddoes not prop-erly acknowledge thecrucial roles of in-digenous Indian and African culturesin Latin American history.14

URGENT PRIORITIES ANDUNANSWERED QUESTIONSIN LATINO CHILD HEALTH

The consortiums guiding conceptualframework was that the special healthneeds and disparities for Latino chil-drenoriginatefrommany factors,includ-inginsufficientmethodologic approachesandinadequateinclusion inresearch, dis-proportionate disease burden and asso-ciated risk factors, special cultural andlinguisticconsiderationsthat affecthealthand health careseeking behaviors,

underrepresentation of Latinos in thehealth care workforce, and substantialaccess barriers to quality health care.

RESEARCH ANDMETHODOLOGIC ISSUES

Lack of suitable, valid research instru-ments for Latino children is recognizedas a concern by all consortium mem-

bers. Such instruments rarely aredesigned with Latino children in mindor in consultation with Latinoresearch-ersand so areunsuitable for Latinochil-dren because they are not culturally orlinguistically appropriate. For example,

analysis of problems in translating thechildandadultsurvey instrumentsoftheConsumer Assessment of Health PlansStudy15 from English to Spanish revealedthatinitial Spanishtranslations weretooawkward, culturallyinappropriate,insuf-ficiently idiomatic,frequently lackinginconceptual equivalence, and at an inap-propriately highreading level forthe tar-get population.

Few child health research instru-ments have been adequatelyvalidatedinLatino populations. For example, theChild Behavior Checklist16 is a com-

monly used standardized assessmentprotocol for child behavior problems,but a MEDLINE review of the litera-ture, conducted in December 2001, re-vealed only onestudy17 on Child Behav-ior Checklist validity for Latino orSpanish-speaking children, whichfoundthat scales for low prevalence prob-lems showed poor internal consistencyin a community sample of children inPuerto Rico. The Conners Parent Rat-ingScale18 andthe Conners Teacher Rat-ing Scale19 also are commonly used re-

search and clinical questionnaires forassessing childhood behavioral prob-lems. In reviewing the literature, we en-countered only 2 studies that exam-ined the validity of the Conners scalesin Latino or Spanish-speaking chil-dren: in separate studies of children inSpain20 and Colombia,21 Spanish ver-sions of theConners Parent Rating Scalehadlower reliabilityand validity than theConners Teacher Rating Scale.

The consortium thus recommendsthatchild health research instruments at

least be validated in Spanish-speakingfamilies, poor and low-literacy popula-tions, communities withsubstantial pro-portions of noncitizens, and all relevantLatinosubgroups(suchasthoseofMexi-can, Puerto Rican, Cuban, Dominican,Central American, and South Americanextraction). Failure to perform such va-lidity tests may result in distorted study

LATINO CHILDRENS HEALTH

2002 American Medical Association. All rights reserved. (Reprinted) JAMA, July 3, 2002Vol 288, No. 1 83

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results22; for example, validity and reli-ability problems, such as the use of in-appropriate response formats and di-chotomization, can substantially biasfindings and conclusions regarding pa-tient satisfaction among Spanish-

speaking patients.

23

Examples of suit-able,well-validatedinstruments availablein both English and Spanish are thePediatric Asthma Symptom Scale24 andthe Oucher, a self-report pain measurecomposed of photographs of a Latinomale adolescent in varying expressionsof pain.25

The ethnicity of study personnel ad-ministering a research instrument or re-cruiting participants may also intro-duce bias:a white male research assistantadministering a survey,for example, maybe viewed with suspicion and as lack-

ing cultural understanding by Latino re-search subjects and their families. Theconsequencescan be withholding or al-tering key information and distortion ofdata when there are immigration con-cerns and instruments are not availablein Spanish. Investigators who under-stand the culture, education, and lit-eracy levels of study subjects can be in-valuable. For example, a study26 foundthateventhoughLatinosbelieve thatpar-ticipating in clinical trialsfor cancer canbe beneficial, theyknewlittle about clini-

cal trials, had basically no opportunityto participate in such trials, and citedmistrust of white people as an impedi-ment to trial participation. Similarly,La-tinopatientswithHIV/AIDS(human im-m uno defi ci ency v i r us/ acq ui r edimmunodeficiency syndrome) are sig-nificantly less likely to be told about,know of, and participate in AIDS clini-cal trials.27 A study28 of predominantlywhite health care practitioners respon-sible for recruiting patients into AIDSclinical trials showed that significantly

fewer practitioners felt comfortablewiththeir ability to explain the trials in cul-turally appropriate terms to Latino pa-tients. On theother hand, a study8 ofac-cess barriers to health care for Latinochildren that used bilingual Latina re-search assistants to administer oral sur-veys in the mothers language of choiceresulted in highparticipation rates, par-

ticularly among difficult-to-reach popu-lations that included noncitizens, re-cent immigrants, andtheuninsured.Thisstudy also employed a successful butun-derusedstrategyfor recruitment of quali-fied Latino research assistants: collabo-

ration with local community-basedorganizations to identifyappropriateper-sonnel. An alternative to using researchassistants to increase recruitment in mi-nority communities is use of peer inter-viewers (trained individuals from thecommunity).29 Given thelow number ofLatinoacademic researchers,training andusing young Latino investigators in re-search on Latinochildren can have mul-tiple benefits. Of course, culturally sen-sitive research with Latino populationsis not simply a matter of ethnic or lan-guage matching, but it is the identifica-

tion of andproper responseto theneedsand preferences of communities andknowledge of how best to communi-cate with the communities citizens.

Latinos frequently are not includedin child health research. The consor-tium identified 3 common errors instudy design that contribute to thisomission. The first error is arbitrarilyexcluding all nonEnglish speakersfrom study enrollment. This problemis particularly egregious when nonEnglish speakers are excluded from

studiesconducted in metropolitan areasandstateswith many Latinos.Data fromsuch studies are distorted by selectionbias and have questionable externalvalidity. Forexample, onestudy30 foundthat only 22% of all articles publishedin major medical journals includednonEnglish-speaking subjects, and51% of authors who excluded nonEnglish-speaking patients from theirstudies admitted that their reason forexclusion wasthatthey hadnot thoughtof the issue. The US Department of

Health and Human Services regula-tions for protection of human subjectsrequire that information in researchfunded by the department be pre-sented in language understandable tothe subject, and subjects who do notspeak English shouldbe presentedwitha consent document written in a lan-guage understandable to them.31

The second error is assuming that astudy sampleis ethnically andraciallydi-verse (or nationally representative)whenonly white and black subjects are en-rolled or analyzed. Latinos (along withAsians/Pacific Islanders and Native

Americans) frequently are omittedfromenrollment or analysis in studies whosefocuspurportsto beracial andethnic dis-parities. National, state, and regionalstudieslimited to suchbiracial compari-sons have limited utility and applicabil-ity. For example,onestudy32 claimed toexamine racial and sex differences insmoking prevalencein responseto priceand tobacco control policies in a na-tionally representative sample of USyouth, but all analyseswere restricted toonly whiteand black subjects.Thus,thesample was not nationally representa-

tive because it omitted not only Latinosbut also all other racial/ethnic groups.

The third error is relegating Latinosand other nonwhiteresearchsubjects toan other category in the analysis andinterpretation ofdata. Such practicescanobscuresignificant racial/ethnicdispari-ties and may reflect bias in subject re-cruitment, such as inadequate efforts toinclude minority participants or exclu-sion ofsubjects with limited English pro-ficiency (LEP).Forexample, in a study33

of corticosteroid prescriptions for asth-

matic children covered by Medicaid inTennessee, data were analyzed by us-ingonly 2 categories: black andwhiteor other. Such a biasedanalysisnot onlyarbitrarily excludes Latino children(thethird largest and fastest growing racial/ethnic group of children in Tennes-see34) but also distorts the study find-ings because the black and white orother groups contain Latinos(whocanbeof any race), and the white or othergroup contains all other racial/ethnicgroups in the state.

Latinochildhealth data rarelyare ana-lyzed by pertinent subgroups. Severalstudies4,7,35-39 have demonstratedthatsub-stantial differences in health and use ofhealth services exist among Latino sub-groups(such asMexican Americans, Pu-ertoRicans, and Cuban Americans) thatwould otherwisebe overlooked andthatcan exceed that magnitude of differ-



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ences among major ethnic and racialgroups. For example, major Latinosub-group differences have been docu-mented for rates of prematurityand lowbirth weight,36 asthma prevalence,4 il-licit drug use,37 vaccination coverage,39

the prevalence of chronic conditions,

38

andseveralindicatorsof healthstatusanduseof services.7,35 Failureto performsub-group analyses canresult in missingcriti-cal findings that can affect child health,policy, and advocacy. In addition, intra-group differences occur that can signifi-cantly affect child health research, in-cluding the childs generational andacculturation level, the childs and par-ents immigration status, parental edu-cational attainment and mental health,family income, geographiclocation, andthe sociopolitical environment of the

community (whether a child and his orher family have social and health sup-port in their community).40,41

The lack of inclusion of Latinos inchild health research is concerning butsimple to remedy. The CCHR recom-mends that, whenever possible, studiesshould examine racial and ethnic dif-ferences in health and identify under-lying factors for such disparities. At aminimum,this would include compari-sons among Latinos, whites, and non-Latino blacks (and Native Americans

and Asians/Pacific Islanders, depend-ing on the population). Researchers,policy makers, and funding agenciesshould ensure that efforts are made toenroll LEP participants, immigrants, andnoncitizens in studies to ensure maxi-mum external validity and avoid selec-tion bias. We also recommend analysesby relevant subgroups, which, for Lati-nos, can include those of Mexican, Pu-erto Rican, Cuban, Dominican, Cen-tral American, and South Americanextraction. The subgroup analysis may

vary, depending on the population, andwill have to be tailored according to de-mographics of the region or study area.In certain regions of the United Stateswithout substantial proportions of Lati-nos, the number of Latinos may be toosmall to permit adequate study enroll-ment and valid analysis by racial/ethnicgroup or Latinosubgroup.Insuch

cases, the consortium recommends thatresearchers present a brief quantitativejustification regardingwhy further analy-sis by racial/ethnic groups and sub-groups is not warranted. Also, to con-duct child health research that will truly

advance the field, factorssuch as accul-turation level, immigration status, andsocioeconomic status that vary withinLatino subgroups also need to be in-cluded in study design and data collec-tion, analysis, and interpretation.

DISPROPORTIONATE DISEASEBURDEN AND ASSOCIATEDRISK FACTORS

Behavioral and

Developmental Issues

There are many unanswered questionsregarding whyLatino childrenare at high

risk for behavioral and developmentaldisorders and what factors are associ-ated with these disorders. For example,it is unclear why Puerto Rican childrenhave among the highest national preva-lence of developmental disorders andfunctional limitations, includingchronicdevelopmental conditions (11%), func-tional limitations (13%), and develop-mental problems by parental report(20%).38 Two extensive literature re-views3,42 of Latinochild healthfoundnopublished studies that specifically ad-

dressed Latino children and such cru-cial issues as school readiness, preva-lence and determinants of attention-deficit/hyperactivity disorder, and theimpact of chronic diseases on develop-ment and functioning, so more investi-gation is needed in these areas. Prelimi-nary research43 indicates that bilingualliteracy promotion can increase literacybehaviors among Latino children andfamilies, but much more work needs tobe done on early literacy issues amongLatinos. More studies areneeded on im-

migrations impacts on family dynam-ics and the effective, culturally appro-priate interventions to help familiesthrough this transition.

Mental Health

There are substantialgaps in our knowl-edge about the mental health needs anduse of services among Latino chil-

dren.44 For example, one study45 foundthat significantly higher proportions ofLatinosthanblackspresented with mor-bid depression, phobias/fears, anxiety/panic, school refusal, and disturbancesof relationships with other children. In

1999,20% of Latinoyouthreported con-sidering suicide, compared with 15% ofblack and 18% of white youth.46 In par-ticular, Latina adolescents (19%) weresignificantlymore likely thanwhite (9%)and black (8%) adolescent girls to haveattempted suicide.46 Few studies, how-ever, have addressed risk factors, men-tal health care access, and outcomes forthese children. Another recent study47

found that Latinos are significantly lesslikely than whites and blacks to be hos-pitalizedfor mental illness in general andspecific diagnoses. Not enough re-

search has been done on causes of thesedisparities, such as referral bias, under-useof mental health care, or barriers re-lated to ethnicity, culture, language, andsocioeconomic status.

Oral Health

The prevalence of dental caries is dis-proportionately higher for Latino chil-dren.48 Amongchildrenaged2to4years,Mexican Americans aremore likelythanwhites and blacks to have caries,untreateddisease,anddecayedandfilled

toothsurfaces.49

Among childrenaged 12to 17years,only30% ofMexican Ameri-cans are free of caries in their perma-nent teeth,comparedwith 32% ofwhitesand41%ofblacks.50 However, only 60%of 12- to 17-year-old Mexican Ameri-cans have hadtheir dentalcaries treatedor filled, compared with 87% of 12- to17-year-old white children.48 In anotherstudy,51 Mexican American adolescentswere twice as likely as white adoles-cents to have at least one untreated car-ies lesion. Studies52,53 indicate a high

prevalence of early childhood cariesamong urban Latino children, rangingfrom 13% in San Antonio, Tex, to 37%inSanFrancisco,Calif.MigrantandruralLatinochildrenare atespecially high riskforcaries andlower numbersof restoredteeth:among children aged 5 to 14years,the mean proportion of teeth with cari-ous surfaces is 65% for migrant chil-



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dren vs17%for USschoolchildren,54 andonly 20% of rural Latino children havefilleddental surfacescomparedwith76%of school children nationwide.55

The reasons for these oral health dis-parities are unclear andneed further in-

vestigation. The roles of accultura-tion, cultural preferences for sugarybeverages, putting infants to sleep withbottles, and mother-child transmis-sion of caries-causing bacteria have notadequately been examined for Latinochildren. Latino children also experi-ence substantial barriers to dental care,including lack of insurance, a dearth ofdentists who accept Medicaid, short-ages of Latinodentists, andcultural andlinguistic obstacles.

Overweight, Obesity,

and Diabetes MellitusLatino boys arethemost overweight andLatina girls the second most over-weight racial/ethnic groups of US chil-dren.56 A recent study57 of poor elemen-tary school Mexican American childrenrevealed that 27% of girls and 23% ofboys wereoverweight.Anextremelyhighprevalence of risk factors for future type2 diabetes was noted in a study of low-income 9-year-old Mexican Americansin Texas,including60% of children withfirst- or second-degree relatives diag-

nosed as having diabetes, 38% with un-acceptablephysical fitnessscores,a highprevalenceof obesity, andeating higher-than-recommended percentages of en-ergy from fat and from saturated fat buthalf the recommended daily fruit andvegetable intake.58 Data59,60 suggest thatthe incidence and prevalence of type 2diabetes are rapidly rising among Lati-nos, with type 2 diabetes accounting for45% of newly diagnosed diabetes casesand31% of all diabetic cases in one Cali-fornia study.59 More research is needed

to determine why Latino children havesuch high risks of obesity and diabetesand what preventive interventions aremost effective.

Asthma and Environmental Health

A half million Latino children haveasthma; two thirds of them are PuertoRican.61 Puerto Rican children have the

highest prevalence of active asthma(11%) of any US ethnic/racial group ofchildren, exceeding by far the preva-lence for blacks (6%) and whites (3%),whereas active asthma is present in only3%of Mexican American and 5%of Cu-

ban American children.

4

In a study ofasthma in New York City Latino fami-lies living on thesame streets and in thesame buildings, Puerto Ricans hada sig-nificantly higher prevalence of asthma(13%) than Dominicans (5%).62 Therea-sons for these dramatic subgroup dif-ferences are still unclear but may be thekey to greater understanding of asthmapathophysiology, prevention, treat-ment, andenvironmental andsocialcor-relates.

Latino children have disproportion-ately greater exposureto outdoor andin-

door air pollutants,63,64 hazardouswastesites,65 pesticides,64 lead,66 and mer-cury,67 which may place them at greaterrisk for morbidity and even prematuredeath from asthma, lead poisoning, be-havioral and developmental problems,andcancer.64,68 For example, 34% ofLati-nos (vs 17% ofblacks and15% ofwhites)live in areas with elevated levels of air-borneparticulatematter,63 which,if fine,areassociated with risk of death from allcauses and fromcardiovascular and res-piratory illnesses.69 Three of the 5 larg-

est hazardous landfills in the UnitedStates are in Latino andblack neighbor-hoods, and the mean percentage of La-tino and black citizens residing in areaswith toxic wastesites is twice that for ar-eas without toxic waste sites.65

Many unanswered questions remain.Which environmental factors are asso-ciated with the increased risk of asthmaamong Latino children? What are theshort- and long-term health conse-quences of higher proportions of Lati-noslivingnext to hazardous waste sites?

Are the increased incidences of certainchildhoodcancers(leukemiaandgonadalgerm cell tumors)70 among Latinosrelatedtotheir increased exposureto pes-ticides and other toxic chemicals?

Thecontributionof environmentalex-posures to childhood diseases is be-lieved to be substantial. An expert com-mittee convened by the National

Research Council concluded that 3% ofneurobehavioral disordersinchildren aredue to environmental neurotoxins, andan additional 25% of these disorders re-sult frominteractions between environ-mental neurotoxins and individual ge-

netic susceptibility.

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Since Latinocommunities often are located in highlycontaminated areas, it is possible thatsome Latino child health disparities maybe the result of disproportionate expo-sures to environmental toxicants.

Health of Migrant Children

Children of migrant Latino farm work-ers are particularly at risk for subopti-mal health and use of services and faceadditional unique health challenges be-cause of their migratory status. Of themore than 1 million childrenwho travel

with their parents annually in pursuit offarmlabor,94%are Latino.72 These chil-dren receive inadequatepreventive care;experience high rates of infectious dis-eases, including tuberculosis, para-sites, and sexually transmitted dis-eases; have inadequate preparation forschool entry and low rates of schoolcompletion; haveimpaired access to ap-propriate day care, forcing parents tobring them to the fields, where they haveincreased risks of pesticide exposuresand injuries; work as farm laborers of-

ten in unsafe working conditions; andare at risk for nutritional disorders,suchas anemia, diabetes,failure to thrive,andobesity.73 In addition, migrant Latinochildrens eligibility forMedicaidand theState Childrens Health Insurance Pro-gram (SCHIP) is hindered by high in-terstate mobility and difficulties withresidency and citizenship status.

There is an urgent need to more ad-equately addressthehealth careandearlyeducationofmigrantLatino children.Mi-grant healthcenters have thecapacity to

serve only 20% of eligible migrant chil-dren, and migrant Head Start programsserve only 15%.72 Specialty, dental, andmental health care are beyond thereachof most migrant Latino children.73 De-spite theexistence of thefederally fundedMigrant Health Program for almost 40years, national data on the health of mi-grant children are lacking.72,73



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Cross-Border Health

Important insights into social, eco-nomic, and policy determinants ofhealth, outcomes, anduseof healthser-vices can be gained from studies of ad-jacent populations separated by an in-

ternational border. For example, abinational survey of depression and sui-cidality comparing Mexican Ameri-can adolescents attending schools inTexas border cities with Mexican ado-lescents attending schools in neighbor-ing Tamaulipas, Mexico, revealed that48% of Mexican American studentsscored above the critical level for de-pression on a standardized scale com-pared with 39% of Mexican youths, and23% of US adolescents reported cur-rent suicidal ideation compared with12% of Mexican students.74 More such

cross-border studies need to be con-ducted on issues such as immuniza-tion coverage, prematurity and lowbirth weight, violence, and use of to-bacco, alcohol, and illicit drugs.

Early Education, School Dropout,

and Health

Latino youth by far have the highestschool dropout rate in thenation, 29%,compared with 13% for blacks and 7%for whites,75 a disparity that persistseven after adjustment for socioeco-

nomic status.76

Latino children face dif-ficultiesin the educational system froman early age, with only 20% of Latinochildren younger than 5 years en-rolled in early childhood education pro-grams, compared with 44% of blacksand 42% of whites.77 Although 36% ofLatino children live in poverty, only26% attend Head Start programs.77 Dis-parities in performance begin as earlyas kindergarten, with a greater propor-tion of Latino children being held backin school, a major predictor of drop-

out in later years.

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The consequences of dropout for La-tino youth include lower earnings,join-inga less skilledworkforce,increased un-employment, and greater demands onsocial services.78 The impact of dispari-ties in early education and school drop-out onthe health ofLatinos ispoorly un-derstood but vitally important.

CULTURAL AND LINGUISTICCONSIDERATIONSCulture and language issues can pro-foundly affect Latino childrens healthand quality of care. Failure to considerthese issues in clinical encounters can

lead to a variety of adverse conse-quences, including decreased satisfac-tion with care, medical errors, difficul-ties with informed consent, inadequateanalgesia, fewer prescriptions, and useof harmful remedies.79,80 Unfortu-nately, cultural competencytraining stillis not an integral part of the educationof pediatricians, pediatricdentists, fam-ily physicians, or nurses. For example,no Canadian medical schools and only8% of all US medical schools have sepa-rate courses addressing cultural is-sues,81 and only 26% of US medical

schools teach Latino cultural issues.81

More research is needed on the most ef-fective course content and structure forteaching cultural issues, along with for-mal evaluation of the effectiveness ofvarious curricula.82 In the meantime,given the substantial evidence that lackof culturally competent care can have amajorimpact on Latinochildrens healthandhealth care,79,80 the consortium rec-ommends that cultural competencytraining be an educational componentin health professions schools, resi-

dency programs, and continuing pro-fessional education.

Much could be learned from Latinocultureabout improving thehealth of allUS children. A growingbody of researchdocuments that first-generation USLatino children have several excellenthealthoutcomes andindicatorsthatdete-riorate with greater acculturation andeachsuccessivegeneration. Forexample,lessacculturationis associated withsig-nificantly lower rates of low birthweight,83 higherimmunizationrates,84,85

less depression and suicidal ideation,

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less cigarette smoking,86 less illicit druguse,87 and older age at first sexual inter-course.88 These findingsare particularlystriking in light of data indicating thatfirst-generation immigrant childrenhavesignificantlydecreasedhealth careaccessanduse.89 Yet we havelittle understand-ingabout what factors areresponsible for

this healthy immigrant effect. Suchfindingsrequire thatwe abandon thetra-ditional deficit view of Latino cultureanditsimpactonhealthandadoptamorebalanced perspective that emphasizesappreciation and understanding of the

salutary components of Latino culture.Language problems can have a sig-nificant impact onmultipleaspects ofthehealth care of Latino children, includ-ing access, health status, use of ser-vices, and outcomes.79,80 In one study8 ofa pediatric primary care clinic, Latinoparents cited language barriers as thesingle greatest barrier to health care ac-cess. Specifically, parents identified thelackof Spanish-speakinghealth carestaffandinadequate interpreter servicesas theprincipal problems. Research docu-ments that medical interpreters are fre-

quently not called when needed, inad-equatelytrained,or notavailable at all.90

Recentwork underscores that lack of ad-equatelytrained medical interpreters canresult in increased medical errors: onestudy91 found that an average of 18 in-terpreter errors of clinical consequenceare made per pediatric encounter, withuntrained interpreters making signifi-cantly more such errorsthan trained in-terpreters. Nevertheless,only 2 US statesprovide third-party reimbursement formedical interpreter services, and fewer

than one quarter of hospitals nation-wide provide anytrainingformedical in-terpreters.92 Recentfederal andstateini-tiatives to protect the rights of LEPpatientsand their familiesincludea presi-dential executive order to improve ac-cess to services for LEP persons,93 anOffice of Civil Rights guidance memo-randum prohibiting discriminationagainst LEP persons,94 and the Massa-chusetts Emergency Room InterpreterServices Act.95 Despite such initiatives,institutions and major medical associa-

tions have expressed reluctance to en-act improvements in interpreter ser-vices and have gone as far as lobbyingmembers of the US Congress to blockthese initiatives because of concernsabout costs.96 A 2002 report to Con-gress by the Office of Management andBudget,however, estimated thatprovid-ing adequate language services to LEP



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persons in thehealthcare systemwouldcost about $4.04 per visit.97

More research is needed on medicalerrors and adverse consequences asso-ciated with having untrained or no in-terpreters for LEP children and their

familiesand the most cost-effective wayto provide comprehensive interpreterservices to LEP populations. The con-sortium recommends that, in areaswhere a substantial proportion of thepopulation speaks Spanish, health pro-fessionsschoolsconsider offering Span-ish language instruction. We also sug-gest that researchersand policy makersconsider third-party payer reimburse-ment for trainedmedicalinterpreter ser-vices as an economically feasible meansof improving the quality and reducingthe cost of care for LEP families.

WORKFORCE ISSUES

Latinos are underrepresented at everylevel of the health careprofessions.98 Al-though 16% of children younger than18 years are Latino, only 3% of medi-cal school faculty,99 5% of pediatri-cians,100 2.8% of dentists,101 and 2% ofnurses102 are Latino. The Latino pedia-trician-to-child ratio is expected to de-crease from 17 Latino pediatricians per100000 Latino childrenin 1996 to 9 per100000 by 2025.103 Analyses indicate

that to achieve parity with future eth-nic changes in the US population, ournation would need twice as many La-tino physicians,104 but there has beena recent decrease in minority medicalschool enrollment, especially in stateswith large Latino populations that havebanned affirmative action policies (Cali-fornia and Texas).105 These trends areparticularly alarming because studiesdocument that Latino communities aresubstantially more likely to have phy-sicianshortages,106 Latinophysiciansare

significantly more likely to care for La-tino and uninsured patients,106 and La-tino patients are more likely to be sat-isfied with health care from Latino vsnon-Latinophysicians.107 Additional re-search is needed on the most effectiveways of increasing the numbers of La-tino health professionals and faculty athealth professions schools.

HEALTH CARE ACCESSAND QUALITYLack of Health Insurance

Latinos are more likely to be unin-sured (27%)than anyother ethnicgroupof US children.108 In comparison, 9% of

white, 18% of black, and 17% of Asian/Pacific Islander children are unin-sured.108 About 3.2 million Latino chil-dren lack health insurance.108 For poorLatino children, lack of health insur-ance is an even greater problem: onethird are uninsured, despiteeligibility ofmost forMedicaid andSCHIP.109 Amonguninsured poor US children, Latinosoutnumber allother racial/ethnic groups,including whites. There are 1.1 millionpoor uninsured Latino children com-paredwith 806000 white,703000 black,and 95000 Asian poor uninsured chil-

dren.109 TheUS CongressenactedSCHIPin1997with a 5-yearinvestment ofmorethan $20 billion. Although 1999 markedthe first timein many years that the pro-portion of uninsuredLatino children ac-tually decreased (from 30% to 27%),108

recent national data suggest that out-reach efforts to enroll Latino childrenhavelargely been unsuccessful.110 A Kai-ser Commission report110 found thatonly 26% of parents of eligible unin-sured children said that they had evertalked to someone or received informa-

tion about Medicaid enrollment, and46% of Spanish-speaking parents wereunsuccessful at enrolling their unin-sured children in Medicaidbecause ma-terials were unavailable in Spanish. Ad-ditionalresearchis needed onidentifyingthemost effective interventions for out-reach and enrollment of uninsured La-tino children, particularlythose whoarepoor, are noncitizens, and have nonciti-zen, LEP, or migrant worker parents.

Access Barriers to Health Care

A comprehensive literature review re-vealed 22 access barriers to health carefrequently encountered by Latino chil-dren, including poverty, low parentaleducational attainment, transportationproblems,excessivewaitingtimesin clin-ics, decreased preventive screening, re-ceipt of proportionally fewer prescrip-tions, language problems, cultural

differences,lack of healthinsurance, andlackofa regular sourceofcare.111 Forex-ample, 30% of Latino children live infamilies with annual incomes belowthefederal poverty level (second only toblack children, at 33%),112 and 37% of

Puerto Rican children live in poverty,making themthe most impoverishedra-cial/ethnic group in the United States.113

Important unanswered questions in-clude: What are effective interventionsto reduce or eliminate such formidablebarriers and What are the health trajec-tories of Latino children with impairedaccess to care?

Disparities in the Quality

of Health Care

Several studies document that Latinochildren frequentlyreceive a lower qual-

ity of health care. Among children withgastroenteritis evaluated at a major chil-drens hospital, Latinos were signifi-cantly less likely than whitesandblacksto undergo diagnostic laboratory testsand radiographic examinations.13

Among preschool children hospital-ized for asthma,Latino children were17times less likely to be prescribed a nebu-lizer for home use at discharge, even af-ter adjustment for relevant confound-ers.12 In a study of children and adultshospitalized for open reduction and in-

ternal fixation of limb fractures, re-searchersfound thatwhitesreceived sig-nificantly higher doses of narcoticanalgesics(22mg/dof morphineequiva-lents) than blacks (16 mg/d) and Lati-nos (13 mg/d), differences that per-sisted after adjustment for relevantcovariates.11 Studies such as these sug-gest that we may need to develop newconceptual frameworks and tech-niques for measuring quality of care forLatino children. Evaluation of medicalerrors, for example, will need to con-

sider the role of language barriers andmedical interpreter errors, sources ofcompromised quality that traditionallyhave not been measured.

CONCLUSIONS

In conclusion, the 2000 census1 docu-ments that Latinos are the predominantracial/ethnic minority group of US chil-



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dren, representing 1 of every 6 US chil-dren. It is time for our health policies,services,and research to address this dra-matic demographic change, which theconsortium believes will be accom-plished through (1)greater inclusionof

Latinochildren in medical research, (2)analysis of study data by pertinent La-tino subgroups, (3)moreresearchonLa-tino child health issues that can eluci-date social and economic determinantsof health and use of health services forall children, such as cross-border healthandthehealthy immigranteffect, (4)en-hancing early educational opportuni-ties for Latino children, (5) traininghealth care professionals more exten-sively in cultural competency, (6) in-creasing the number of Latinosin healthcareprofessions, and(7)eliminating dis-

parities in access to care, mental health,immunization coverage, oral health,quality ofcare, andenvironmentalhealth.

Disclaimer: The views expressed herein may not re-flect theviewsof theOffice of Minority Healthor theDepartmentof Healthand Human Services. TheCCHRis an independent operating branch of the AmericanAcademy of Pediatrics. The content expressed hereindoes not necessarily reflect the views of the CCHR orthe American Academy of Pediatrics.Funding/Support: Dr Floresis supportedby an Inde-pendent Scientist (KO2) Award from the Agency forHealthcare Research and Quality and Minority Medi-cal FacultyDevelopment andGeneralistPhysician Fac-ulty Scholars Awards fromThe Robert WoodJohnsonFoundation.

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