Health service access across racial/ethnic groups of children in the child welfare system

https://doi.org/10.1016/j.chiabu.2008.11.003Get rights and content

Abstract

Objective

This study examined health service access among children of different racial/ethnic groups in the child welfare system in an attempt to identify and explain disparities.

Methods

Data were from the National Survey of Child and Adolescent Well-Being (NSCAW). N for descriptive statistics = 2,505. N for multiple regression model = 537. Measures reflected child health services need, access, and enabling factors. Chi-square and t tests were used to compare across racial/ethnic groups. A logistic regression model further explored the greatest disparity identified, that between non-Latino/a Black and White children in caseworker-reported access to counseling.

Results

In general, caseworker reports of health care service receipt did not differ across racial/ethnic groups. However, Latino/a children had better reported access to vision services than non-Latino/a White children, and counseling access was lower for non-Latino/a Black children than non-Latino/a White children. Caseworkers’ self-reported efforts to facilitate service access did not vary by race/ethnicity for any type of health care. In the multiple regression model, both private health insurance and a lack of insurance were negatively associated with counseling access, while a history of sexual abuse, adolescence, and greater caseworker effort to secure services were positively associated with access. Race was just barely nonsignificant after controlling for other factors expected to affect access.

Conclusions

One possible reason why Black children are less likely to be identified as needing counseling is the fact that they are less likely than White children to have reports of sexual abuse, which strongly predicts counseling access.

Practice implications

First, child welfare practice may be more equitable than many believe, with generally comparable health service access reported across children's racial/ethnic groups. Second, caseworkers may be under-identifying need for counseling services among Black children, although this might reflect less frequent reports of sexual abuse for Black children. Third, both privately insured and uninsured children were less likely to receive needed mental health counseling than those with public insurance. This suggests that policy makers should focus on increasing the numbers of children enrolled in public health insurance programs such as Medicaid and the State Children's Health Insurance Program (SCHIP).

Introduction

The child welfare system is a particularly compelling context for examining disparities in health service access both because these children are extremely vulnerable and because, at least theoretically, child welfare agencies can facilitate access to needed services. Children in the child welfare system have been shown to have disproportionately high rates of health problems (Boyle et al., 1994, Burns et al., 2004a, Leslie et al., 2005a, Stahmer et al., 2005, Stein et al., 1996) and one recent study found that 87% had some form of physical, developmental, or mental health need (Leslie, Gordon, Meneken et al., 2005).

Non-White children in the child welfare system appear to have especially poor access to formal treatment for physical and mental health problems (health services). In particular, these children receive fewer mental health services than White children, even controlling for mental health problem severity, type of maltreatment, age, sex, insurance, and placement (Garland and Besinger, 1997, Garland et al., 2003, Hurlburt et al., 2004, Leslie et al., 2005c, Leslie et al., 2004, Zima et al., 2000). Potential reasons for racial/ethnic disparities in health service utilization include differences across groups in need for care as well as factors that facilitate access to needed care. For instance, there may be variation across racial/ethnic groups in physical or behavioral problems and/or in the types of maltreatment that children experience. There may also be tendencies to over or under-report health problems of children of different racial/ethnic groups. Racial/ethnic groups may also vary in other demographic attributes, such as age profile, that in aggregate create developmental differences affecting need for care. In addition, the professionals who seek to help these children may perceive need differentially across racial/ethnic groups.

Once need is identified, a range of factors may enable children to access care. At the individual level, health insurance is recognized as a key predictor of health service use (Andersen, 1995). In the aggregate, “health personnel and facilities must be available where people live and work. Then people must have the means and know-how to get to those services and make use of them” (Andersen, 1995, p. 3). For children, this means that caregivers and professionals must deploy such knowledge on their behalf.

For children in the child welfare system, the system itself may also facilitate or impede access to services in ways that privilege children of some racial/ethnic groups over others. As ‘gateways’ between children and services (Stiffman, Pescosolido, & Cabassa, 2004), child welfare caseworkers play a pivotal role in facilitating access. One concern has been that caseworker ignorance or bias may lead to differential patterns of referrals across racial/ethnic groups, although the few studies conducted thus far on this issue have not found evidence directly supporting this concern. A review of court records for 142 children in foster care did not reveal differences in caseworker recommendations for services across children's racial/ethnic groups, although courts were less likely to direct African American than White children to counseling or psychotherapy (Garland & Besinger, 1997). Among 203 6-12-year olds in the Los Angeles foster care system, race/ethnicity was not a significant predictor of referrals to specialty mental health care services in models controlling for child and foster parent attributes, although among children diagnosed with Attention-Deficit/Hyperactivity Disorder White children were more likely to receive these services (Zima, Bussing, Yang, & Belin, 2000).

Children in different racial/ethnic groups may also tend to be served by different child welfare agencies because of residential segregation. Thus, there may be differences in children's service access not because of discriminatory practices within agencies, but because of differences across agencies. For instance, if non-White children are in agencies with fewer ties to service providers, this could affect their likelihood of service receipt. Previous evidence suggests that children in some racial/ethnic groups are disproportionately located in resource-poor areas (Chipungu and Bent-Goodley, 2004, Church et al., 2005, Hines et al., 2004, Roberts, 2002).

To date, there has been no comprehensive comparison of health service access for children in the child welfare system who are of different race/ethnicities. In addition, despite recent advances in understanding potential causes of identified disparities (Garland and Besinger, 1997, Hurlburt et al., 2004), the analyses have generally not been able to explain fully the effects of race with correlated factors such as family income (Garland and Besinger, 1997, Garland et al., 2003, Leslie et al., 2004, Zima et al., 2000). The study reported here therefore compared several major types of health service access as well as child need and enabling factors among non-Latino/a White, non-Latino/a Black, and Latino/a children in the child welfare system. Among the enabling factors examined was caseworker effort to facilitate access to needed services. We also use contextual sources to understand better differences in access across racial/ethnic groups.

Section snippets

Sample

The National Survey of Child and Adolescent Well-Being (NSCAW) began with 5,501 children ages 0-14 who were subjects of completed child abuse and neglect investigations during a 15-month period beginning in October 1999 (Dowd et al., 2002). Data for this paper are from the initial two waves of this study, which occurred approximately 2-6 and 12 months after the close of each case investigation or assessment. Because we were interested in child welfare experiences, we restricted our sample to

Results

Table 1 shows few differences across racial/ethnic groups in caseworkers’ perceptions of either need or access after referrals. Caseworkers were less likely to report that White (42.9%) than Black children (51.6%) had unmet immunization/check up needs. Caseworkers were more likely to believe that Latino/a children (15.2%) needed vision care than non-Latino/a White children (8.3%). They were also more likely to believe that White children (34.5%) than Black children (24.1%) needed mental health

Conclusions

This inquiry sought to identify and explain racial/ethnic disparities in perceived health service access among children in the child welfare system. Findings indicate generally comparable access, with differences not consistently disadvantaging any one group. Caseworkers typically reported that they had obtained the services they had recommended for abused and neglected children. Moreover, in the six dimensions of health care services studied, there were racial/ethnic differences in only two.

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    This study has been supported by NIDA R03 DA020748-01A1. This document includes data from the National Survey on Child and Adolescent Well-Being, which was developed under contract with the Administration on Children, Youth, and Families, U.S. Department of Health and Human Services (ACYF/DHHS). The data have been provided by the National Data Archive on Child Abuse and Neglect. The information and opinions expressed herein reflect solely the position of the author(s). Nothing herein should be construed to indicate the support or endorsement of its content by ACYF/DHHS.

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