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

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

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

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

Parental Attitudes on Social Media Monitoring for Youth: Cross-Sectional Survey Study.

Background: Online environments dominate the daily lives of American youth and pose evolving challenges to their health and well-being. Recent national poll data indicate that social media overuse, internet safety, and online bullying are among parents' top child health concerns, particularly during the COVID-19 pandemic. While parents are uniquely positioned to help youth navigate social media, their attitudes on monitoring media use may be impacted by a myriad of personal and family factors. Objective: This study aimed to examine factors associated with parental attitudes about monitoring social media use among youth. Methods: Data were analyzed from the Voices of Child Health in Chicago Parent Panel Survey, administered to parents over the web and by telephone. Parents with at least 1 child aged ≥11 years responded to questions about bullying and social media monitoring from May to July 2020. The primary outcome was their response to the following question: "Do you think parents should monitor their children's use of social media platforms such as Facebook, Twitter, and Instagram?" Bivariate analyses and multivariable logistic regression were used to examine parental agreement with frequent social media monitoring and concerns about bullying, adjusted for sociodemographic characteristics. Analyses were weighted to represent the parent population of Chicago. Results: Among 1613 survey respondents, the analyzed sample included 808 parents with at least 1 child aged ≥11 years. Overall, 62.9% (n=566) of parents agreed with frequent parental monitoring of their children's social media use. Compared with parents aged ≤35 years, parents who were >35 years old were significantly less likely to agree with frequent social media monitoring (adjusted odds ratio [aOR] 0.45, 95% CI 0.25-0.81). Parents expressing a high level of concern regarding the effects of bullying were more likely to agree with frequent monitoring of youth social media (aOR 2.15, 95% CI 1.24-3.73). Conclusions: Parents' personal characteristics and concerns about bullying may influence their attitudes toward monitoring social media use among youth. Given the potential impact of these attitudes on parental monitoring behaviors and the subsequent health impact on youth, pediatricians should consider these factors when counseling about bullying and social media. Child health professionals can support families in developing a safe media use plan that fits family circumstances.

Habitat attributes mediate herbivory and influence community development in algal metacommunities.

Understanding the drivers and impacts of spatiotemporal variation in species abundance on community trajectories is key to understanding the factors contributing to ecosystem resilience. Temporal variation in species trajectories across patches can provide compensation for species loss and can influence successional patterns. However, little is known about the underlying mechanisms that lead to patterns of species or spatial compensation and how those patterns may be mediated by consumer-resource relationships. Here we describe an experiment testing whether habitat attributes (e.g., structural complexity and spatial heterogeneity) mediate the effects of herbivory on tropical marine macroalgal communities by reducing accessibility and detectability, respectively, leading to variable trajectories among algal species at community (within patch) and metacommunity (i.e., among patch) scales. Reduced accessibility (greater habitat complexity) decreased the effects of herbivory (i.e., depressed consumption rate, increased algal species richness), and both accessibility and detectability (spatial heterogeneity) influenced algal community structure. Moreover, decreased accessibility at the community scale and a mosaic of accessibility at the metacommunity scale led to variation in community assembly. We suggest that habitat attributes can be important influencers of consumer-resource interactions on coral reefs, which in turn can increase species diversity, promote species succession, and enhance stability in algal metacommunities.

Moving Beyond Words: Leveraging Financial Resources to Improve Diversity, Equity, and Inclusion in Academic Medical Centers.

Diversity, equity, and inclusion (DEI) efforts at academic medical centers (AMCs) began prior to 2020, but have been accelerated after the death of George Floyd, leading many AMCs to recommit their support for DEI. Institutions crafted statements to decry racism, but we assert that institutions must make a transparent, continuous, and robust financial investment to truly show their commitment to DEI. This financial investment should focus on (1) advocacy efforts for programs that will contribute to DEI in health, (2) pipeline programs to support and guide minoritized students to enter health professions, and (3) the recruitment and retention of minoritized faculty. While financial investments will not eliminate all DEI concerns within AMCs, investing significant financial resources consistently and intentionally will better position AMCs to truly advance diversity, equity, and inclusion within healthcare, the community, and beyond.

Adolescents' Experiences, Emotions, and Coping Strategies Associated With Exposure to Media-Based Vicarious Racism.

Importance: Adolescents frequently encounter racism vicariously through online news and social media and may experience negative emotional responses due to these exposures. To mitigate potential adverse health impacts, including negative emotional health, it is important to understand how adolescents cope with these exposures. Objectives: To examine adolescents' responses to online and media-based vicarious racism exposure and to explore coping strategies, particularly positive coping strategies, that may be used to combat negative emotions. Design, Setting, and Participants: This qualitative study rooted in phenomenological research methods conducted 4 semistructured focus groups, with 3 to 6 English-speaking adolescents (aged 13-19 years) in each group, between November 2018 and April 2019. Focus groups were facilitated by 2 research team members. The study was conducted at community sites and youth organizations in the greater Chicago, Illinois, area. Interview transcripts were analyzed thematically. Exposures: Lived experiences of media-based vicarious racism. Main Outcomes and Measures: Focus group participants shared their experiences with media-based vicarious racism online, including their responses to exposure and the coping strategies used. Results: Four focus group sessions were conducted with a total of 18 adolescents. Participants had a mean (SD) age of 16.4 (1.6) years. Overall, 7 participants (39%) self-identified as Black/African American, 8 (44%) as Hispanic/Latinx, and 3 (17%) as White individuals; 7 (39%) were in grades 7 to 9, 8 (44%) in grades 10 to 12 grade, and 3 (17%) at the college or university level. Central themes emerged related to adolescents' experiences, including their emotional and coping responses to media-based vicarious racism. Many participants reported helplessness as a major negative emotion associated with these exposures. Activism was endorsed as a key positive coping strategy that participants used, including online and in-person modalities. Conclusions and Relevance: The findings from this qualitative study suggest adolescents may experience helplessness as a primary negative emotion after exposure to media-based vicarious racism and activism may serve as a coping mechanism. Activism may represent an important and constructive means by which adolescents cope with and combat structural racism, mitigate negative emotions, and potentially prevent adverse health effects.

"Melanincholy": A Qualitative Exploration of Youth Media Use, Vicarious Racism, and Perceptions of Health.

PURPOSE: We sought to (1) characterize teens' experiences with news and social media, focusing on news depicting racism, (2) assess youth perceptions of how these experiences may impact their own health, and (3) explore how teens cope with racism encountered in media. We hypothesized that teens access news primarily through social media, and vicarious racism experienced via news increases negative perceptions of health. METHODS: Eighteen teens (aged 13-19 years) were recruited to participate in focus group interviews (N = 4). These were recorded, transcribed, and coded using qualitative methods. RESULTS: Youth spend much of each day online and frequently access social media, including news shared on these platforms. Many participants identified concerns surrounding "fake" news on social media. Participants reported encountering racially charged news and described their responses to these stories. Some reported feeling overwhelmed by racism in the news. Most participants perceived negative mood changes after exposure to racism in online news, although few associated this exposure with changes in their own health behaviors. Youth indicated that peer discussion was important for coping with vicarious racism exposure. CONCLUSIONS: This study provides insight into the way teens access and share information through social media, including news involving racism, and the effect that this information may have on them. Their vicarious experiences of racism in the news may be associated with feelings of desensitization and mood changes, with potential downstream effects on health. Peer support may help teens cope with vicarious racism. Longitudinal studies examining these exposures' health effects and opportunities for cross-sector intervention are needed.

Association of Childhood History of Parental Incarceration and Juvenile Justice Involvement With Mental Health in Early Adulthood.

Importance: Young adults with a childhood history of parental incarceration (PI) or juvenile justice involvement (JJI) are more likely to have worse mental health outcomes than their peers. However, the association between mental health and exposure to both PI and JJI (PI plus JJI) is unclear. Objective: To determine the association of PI plus JJI exposure with mental health outcomes in young adulthood. Design, Setting, and Participants: A cross-sectional study of the US National Longitudinal Survey of Adolescent to Adult Health was conducted to examine the associations between PI, JJI, and PI plus JJI and mental health outcomes (ie, depression, anxiety, posttraumatic stress disorder, suicidal ideation, and mental health counseling). In-home interviews were conducted of 13 083 participants; 704 participants with PI after age 18 years were excluded, and 12 379 participants formed the analysis sample. Participants were in grades 7 to 12 in 1994 to 1995 and were ages 24 to 32 years at follow-up in 2008. Data analysis was completed in 2019. Exposures: Parental incarceration, JJI, or PI plus JJI before age 18 years. Main Outcomes and Measures: Mental health outcomes in early adulthood (ages 24-32 years). The analysis included multivariable logistic regression models; accounted for individual, family, and geographic-level factors; and generated adjusted odds ratios. Results: Among 13 083 participants (6962 female; weighted proportion, 49.6%) with a mean age at wave 1 of 15.4 years (95% CI, 15.2-15.7 years), 10 499 (80.2%) did not have a history of PI or JJI, 1247 (9.1%) had childhood PI, 704 (5.2%) had PI after age 18 years, 492 (4.5%) had JJI only, and 141 (1.2%) had PI plus JJI. Sociodemographic characteristics varied by exposure. Exposure to both PI and JJI was associated with a greater risk of depression (adjusted odds ratio, 2.80; 95% CI, 1.60-4.90), anxiety (adjusted odds ratio, 1.89; 95% CI, 1.08-3.31), and posttraumatic stress disorder (adjusted odds ratio, 2.92; 95% CI, 1.09-7.82) compared with peers with neither exposure. Exposure to both PI and JJI did not have an additive association with mental health beyond PI or JJI alone. Conclusions and Relevance: This study suggests that exposure to the criminal justice system during childhood places individuals at risk for poor mental health outcomes in early adulthood. Clinical, advocacy, and policy efforts that prioritize reducing the impact of the US criminal justice system on children may yield substantive improvements in the mental well-being of those individuals as adults.

The role of perceived discrimination during childhood and adolescence in understanding racial and socioeconomic influences on depression in young adulthood.

OBJECTIVE: To describe levels of perceived lifetime discrimination among young adults and determine its role in understanding this racial/ethnic disparity. STUDY DESIGN: Data were from the Princeton School District study, a 10-year cohort study in which investigators followed 545 non-Hispanic black (46%) and white initial 5-12 graders. Perceived lifetime racial discrimination was assessed with the General Ethnic Discrimination Scale and depressive symptoms with the Center for Epidemiological Studies Depression Scale. Stepped linear and logistic regression analyses assessed the relationships of race/ethnicity, parental education, and quintiles of discrimination to depressive symptoms. Stratification by race/ethnicity explored differences in the role of discrimination in explaining the relationship between parental education and depressive symptoms. RESULTS: Black students from professionally educated families had the greatest discrimination scores, 1.8 times greater than among their white peers (meanblack = 42.1 vs meanwhite = 22.8; P < .0001). Greater parental education was associated with lower depressive symptoms in all regression models. Race/ethnicity became predictive of depressive symptoms only after adjusting for discrimination, which was strongly associated with depressive symptoms. Stratified analysis suggested discrimination accounted for the relationship of parental education to depressive symptoms among whites. Among black subjects, accounting for discrimination unmasked a buffering effect of parental education. CONCLUSIONS: Greater levels of parent education are protective against depression for white youth. However, for black youth, greater parent education confers both risk and protective effects. The high discrimination among black youth from families with college or professionally educated parents overwhelms the protective effect of greater levels of parent education.

Multiple vantage points on the mental health effects of mass shootings.

The phenomenon of mass shootings has emerged over the past 50 years. A high proportion of rampage shootings have occurred in the United States, and secondarily, in European nations with otherwise low firearm homicide rates; yet, paradoxically, shooting massacres are not prominent in the Latin American nations with the highest firearm homicide rates in the world. A review of the scientific literature from 2010 to early 2014 reveals that, at the individual level, mental health effects include psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident. Psychological repercussions extend to the surrounding affected community. In the aftermath of the deadliest mass shooting on record, Norway has been in the vanguard of intervention research focusing on rapid delivery of psychological support and services to survivors of the "Oslo Terror." Grounded on a detailed review of the clinical literature on the mental health effects of mass shootings, this paper also incorporates wide-ranging co-author expertise to delineate: 1) the patterning of mass shootings within the international context of firearm homicides, 2) the effects of shooting rampages on children and adolescents, 3) the psychological effects for wounded victims and the emergency healthcare personnel who care for them, 4) the disaster behavioral health considerations for preparedness and response, and 5) the media "framing" of mass shooting incidents in relation to the portrayal of mental health themes.

Asthma medication adherence among urban teens: a qualitative analysis of barriers, facilitators and experiences with school-based care.

OBJECTIVE: Teens with persistent asthma do not always receive daily preventive medications or do not take them as prescribed, despite established clinical guidelines. The purpose of this study was to understand urban teens' experiences with asthma management, preventive medication adherence and participation in a school-based intervention. METHODS: Teens (12-15 years) with persistent asthma, and prescribed preventive medication, participated in a pilot study that included daily observed medication therapy at school and motivational interviewing. Semi-structured interviews occurred at final survey. Qualitative content analysis enabled data coding to identify themes. RESULTS: Themes were classified as "general asthma management" or "program-specific." For general management, routines were important, while hurrying interfered with taking medications. Forgetfulness was most commonly linked to medication nonadherence. Competing demands related to school preparedness and social priorities were barriers to medication use. Independence with medications was associated with several benefits (e.g. avoiding parental nagging and feeling responsible/mature). Program-specific experiences varied. Half of teens reported positive rapport with their school nurse, while a few felt that their nurse was dismissive. Unexpected benefits and barriers within the school structure included perceptions about leaving the classroom, the distance to the nurse's office, the necessity of hall passes and morning school routines. Importantly, many teens connected daily medication use with fewer asthma symptoms, incenting continued adherence. CONCLUSIONS: Teens with asthma benefit from adherence to preventive medications but encounter numerous barriers to proper use. Interventions to improve adherence must accommodate school demands and unique teen priorities. The school nurse's role as an ally may support teens' transition to medication independence.

The Sandy Hook Elementary School shooting as tipping point: "This Time Is Different".

Among rampage shooting massacres, the Sandy Hook Elementary School shooting on December 14, 2012 galvanized public attention. In this Commentary we examine the features of this episode of gun violence that has sparked strong reactions and energized discourse that may ultimately lead toward constructive solutions to diminish high rates of firearm deaths and injuries in the United States.

Fatal school shootings and the epidemiological context of firearm mortality in the United States.

Background The December 14, 2012 mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, USA, vaulted concerns regarding gun violence to the forefront of public attention. This high-visibility incident occurred within the epidemiological context of U.S. firearm mortality that claims more than 88 lives daily. Methods National epidemiologic data on firearm deaths over two decades were analyzed along with data registries on school shootings in order to place the tragedy at Sandy Hook in perspective. School shootings were classified as random or targeted. Results The U.S. has the highest rates of firearm deaths, suicides, and homicides among the world's 34 "advanced economies." Seventy percent of U.S. homicides and more than 50% of U.S. suicides are committed using a firearm. U.S. firearm homicide rates first declined, and then stabilized, during the past 23 years, 1990-2012. "Shooting massacres" in school settings, a new phenomenon within the past 50 years, are extremely rare events. Over 23 years, 1990-2012, 215 fatal school shooting incidents resulted in 363 deaths, equivalent to 0.12% of national firearm homicides during that time period. Most episodes were "targeted" shootings in which the perpetrator intentionally killed a specific individual in a school setting. Only 25 of these 215 events (11.6%) were "random" or "rampage" shootings, resulting in 135 deaths (0.04% of national firearm homicides). Among these, just three shooting rampages - Columbine High School, Virginia Tech University, and Sandy hook Elementary School - accounted for 72 (53.3%) of these 135 deaths. The frequency of random/rampage shooting incidents in schools has remained within the narrow range of 0 to 3 episodes per year. Conclusions Each year, more than 32,000 Americans die by firearms and more than 70,000 are wounded, representing a volume of preventable deaths and injuries that the U.S. government describes as a "public health crisis." School massacres, such as Sandy Hook, occur periodically, galvanizing public reaction and bringing forth a collective call for intervention. Epidemiological analyses position these rare, but uniquely compelling, incidents within the broader national patterns of gun violence. The intention is to inform the selection of a balanced, comprehensive set of effective remedies to address the daily death toll from firearm suicides and "targeted" firearm homicides that account for more than 99% of firearm fatalities; as well as the rare, random, and sporadic rampage shootings in school or community settings.