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Am J Public Health. 2000 September; 90(9): 1436–1443.
PMCID: PMC1447611

Well child care in the United States: racial differences in compliance with guidelines.


OBJECTIVES: This study sought to estimate the rate of compliance with American Academy of Pediatrics guidelines for well child care in the first 6 months of life and to determine risks for inadequate care. METHODS: The study included 7776 infants whose mothers participated in both the 1988 National Maternal and Infant Health Survey and its 1991 longitudinal follow-up and whose mothers or pediatric providers supplied information about their medical care. Regression analysis was used to determine the probability of incomplete compliance with guidelines for well child care in relation to several socioeconomic risks. RESULTS: Fifty-eight percent of White infants, 35% of African American infants, and 37% of Hispanic infants obtained all recommended well child care. African American race was the biggest risk for inadequate care (odds ratio = 1.7, 95% confidence interval = 1.5, 1.9), followed by low levels of maternal education, low income, and poor prenatal care. The risk for African American infants persisted across socioeconomic levels. CONCLUSIONS: The racial disparities identified suggest that cultural barriers to seeking preventive care need further study and that programs aimed at reducing these barriers need to be developed.

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  • Rep M, Nooy J, Guélin E, Grivell LA. Three genes for mitochondrial proteins suppress null-mutations in both Afg3 and Rca1 when over-expressed. Curr Genet. 1996 Aug;30(3):206–211. [PubMed]
  • Stockwell EG, Goza FW. Racial differences in the relationship between infant mortality and socioeconomic status. J Biosoc Sci. 1996 Jan;28(1):73–84. [PubMed]
  • Gortmaker SL, Clark CJ, Graven SN, Sobol AM, Geronimus A. Reducing infant mortality in rural America: evaluation of the Rural Infant Care Program. Health Serv Res. 1987 Apr;22(1):91–116. [PMC free article] [PubMed]
  • Alo CJ, Howe HL, Nelson MR. Birth-weight-specific infant mortality risks and leading causes of death. Illinois, 1980-1989. Am J Dis Child. 1993 Oct;147(10):1085–1089. [PubMed]
  • Newacheck PW, Starfield B. Morbidity and use of ambulatory care services among poor and nonpoor children. Am J Public Health. 1988 Aug;78(8):927–933. [PMC free article] [PubMed]
  • Newacheck PW, Stoddard JJ, McManus M. Ethnocultural variations in the prevalence and impact of childhood chronic conditions. Pediatrics. 1993 May;91(5 Pt 2):1031–1039. [PubMed]
  • Lozano P, Connell FA, Koepsell TD. Use of health services by African-American children with asthma on Medicaid. JAMA. 1995 Aug 9;274(6):469–473. [PubMed]
  • Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups. Am J Public Health. 1997 May;87(5):811–816. [PMC free article] [PubMed]
  • Gemperline P, Brockert J, Osborn LM. Preventive health care utilization. Prenatal and the first 3 years in a Utah population. Clin Pediatr (Phila) 1989 Jan;28(1):34–37. [PubMed]
  • Short PF, Lefkowitz DC. Encouraging preventive services for low-income children. The effect of expanding Medicaid. Med Care. 1992 Sep;30(9):766–780. [PubMed]
  • Gadomski AM, Talarico J, Abernethy KS, Cicirello HG. Population-based study of the adequacy of well-child care services: a rural county's report card. Arch Pediatr Adolesc Med. 1998 Aug;152(8):745–748. [PubMed]
  • Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. American Academy of Pediatrics. Pediatrics. 1999 Sep;104(3 Pt 1):536–540. [PubMed]
  • Mustin HD, Holt VL, Connell FA. Adequacy of well-child care and immunizations in US infants born in 1988. JAMA. 1994 Oct 12;272(14):1111–1115. [PubMed]
  • Newacheck PW, Hughes DC, Stoddard JJ. Children's access to primary care: differences by race, income, and insurance status. Pediatrics. 1996 Jan;97(1):26–32. [PubMed]
  • Stoddard JJ, St Peter RF, Newacheck PW. Health insurance status and ambulatory care for children. N Engl J Med. 1994 May 19;330(20):1421–1425. [PubMed]
  • David RJ, Collins JW., Jr Differing birth weight among infants of U.S.-born blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997 Oct 23;337(17):1209–1214. [PubMed]
  • Sanderson M, Placek PJ, Keppel KG. The 1988 National Maternal and Infant Health Survey: design, content, and data availability. Birth. 1991 Mar;18(1):26–32. [PubMed]
  • Kotelchuck M. An evaluation of the Kessner Adequacy of Prenatal Care Index and a proposed Adequacy of Prenatal Care Utilization Index. Am J Public Health. 1994 Sep;84(9):1414–1420. [PMC free article] [PubMed]
  • Zell ER, Dietz V, Stevenson J, Cochi S, Bruce RH. Low vaccination levels of US preschool and school-age children. Retrospective assessments of vaccination coverage, 1991-1992. JAMA. 1994 Mar 16;271(11):833–839. [PubMed]
  • Szilagyi PG, Rodewald LE, Humiston SG, Raubertas RF, Cove LA, Doane CB, Lind PH, Tobin MS, Roghmann KJ, Hall CB. Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status. Pediatrics. 1993 Jan;91(1):1–7. [PubMed]
  • Brown J, Melinkovich P, Gitterman B, Ricketts S. Missed opportunities in preventive pediatric health care. Immunizations or well-child care visits? Am J Dis Child. 1993 Oct;147(10):1081–1084. [PubMed]
  • Rodewald LE, Szilagyi PG, Holl J, Shone LR, Zwanziger J, Raubertas RF. Health insurance for low-income working families. Effect on the provision of immunizations to preschool-age children. Arch Pediatr Adolesc Med. 1997 Aug;151(8):798–803. [PubMed]
  • Rodewald LE, Szilagyi PG, Shiuh T, Humiston SG, LeBaron C, Hall CB. Is underimmunization a marker for insufficient utilization of preventive and primary care? Arch Pediatr Adolesc Med. 1995 Apr;149(4):393–397. [PubMed]
  • Wood D, Pereyra M, Halfon N, Hamlin J, Grabowsky M. Vaccination levels in Los Angeles public health centers: the contribution of missed opportunities to vaccinate and other factors. Am J Public Health. 1995 Jun;85(6):850–853. [PMC free article] [PubMed]
  • Bordley WC, Margolis PA, Lannon CM. The delivery of immunizations and other preventive services in private practices. Pediatrics. 1996 Apr;97(4):467–473. [PubMed]
  • Taylor JA, Darden PM, Slora E, Hasemeier CM, Asmussen L, Wasserman R. The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: a study from Pediatric Research in Office Settings. Pediatrics. 1997 Feb;99(2):209–215. [PubMed]
  • Lieu TA, Black SB, Sorel ME, Ray P, Shinefield HR. Would better adherence to guidelines improve childhood immunization rates? Pediatrics. 1996 Dec;98(6 Pt 1):1062–1068. [PubMed]
  • Pierce C, Goldstein M, Suozzi K, Gallaher M, Dietz V, Stevenson J. The impact of the standards for pediatric immunization practices on vaccination coverage levels. JAMA. 1996 Aug 28;276(8):626–630. [PubMed]
  • Bobo JK, Gale JL, Thapa PB, Wassilak SG. Risk factors for delayed immunization in a random sample of 1163 children from Oregon and Washington. Pediatrics. 1993 Feb;91(2):308–314. [PubMed]
  • Strobino D, Keane V, Holt E, Hughart N, Guyer B. Parental attitudes do not explain underimmunization. Pediatrics. 1996 Dec;98(6 Pt 1):1076–1083. [PubMed]
  • Moore P, Hepworth JT. Use of perinatal and infant health services by Mexican-American Medicaid enrollees. JAMA. 1994 Jul 27;272(4):297–304. [PubMed]
  • Weitzman M, Byrd RS, Auinger P. Black and white middle class children who have private health insurance in the United States. Pediatrics. 1999 Jul;104(1 Pt 2):151–157. [PubMed]
  • Cleland JG, Van Ginneken JK. Maternal education and child survival in developing countries: the search for pathways of influence. Soc Sci Med. 1988;27(12):1357–1368. [PubMed]
  • Gornick ME, Eggers PW, Reilly TW, Mentnech RM, Fitterman LK, Kucken LE, Vladeck BC. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med. 1996 Sep 12;335(11):791–799. [PubMed]
  • Mustard CA, Mayer T, Black C, Postl B. Continuity of pediatric ambulatory care in a universally insured population. Pediatrics. 1996 Dec;98(6 Pt 1):1028–1034. [PubMed]
  • Fielding JE, Cumberland WG, Pettitt L. Immunization status of children of employees in a large corporation. JAMA. 1994 Feb 16;271(7):525–530. [PubMed]
  • Schoendorf KC, Hogue CJ, Kleinman JC, Rowley D. Mortality among infants of black as compared with white college-educated parents. N Engl J Med. 1992 Jun 4;326(23):1522–1526. [PubMed]
  • Kotelchuck M. The Adequacy of Prenatal Care Utilization Index: its US distribution and association with low birthweight. Am J Public Health. 1994 Sep;84(9):1486–1489. [PMC free article] [PubMed]
  • Pappas G. Elucidating the relationships between race, socioeconomic status, and health. Am J Public Health. 1994 Jun;84(6):892–893. [PMC free article] [PubMed]
  • Pérez-Stable EJ, Marín G, Marín BV. Behavioral risk factors: a comparison of Latinos and non-Latino whites in San Francisco. Am J Public Health. 1994 Jun;84(6):971–976. [PMC free article] [PubMed]
  • Newacheck PW. Poverty and childhood chronic illness. Arch Pediatr Adolesc Med. 1994 Nov;148(11):1143–1149. [PubMed]
  • Krieger N, Rowley DL, Herman AA, Avery B, Phillips MT. Racism, sexism, and social class: implications for studies of health, disease, and well-being. Am J Prev Med. 1993 Nov-Dec;9(6 Suppl):82–122. [PubMed]
  • David RJ, Collins JW., Jr Bad outcomes in black babies: race or racism? Ethn Dis. 1991 Summer;1(3):236–244. [PubMed]
  • Gamble VN. A legacy of distrust: African Americans and medical research. Am J Prev Med. 1993 Nov-Dec;9(6 Suppl):35–38. [PubMed]
  • Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94. [PubMed]
  • Kleinman JC. The slowdown in the infant mortality decline. Paediatr Perinat Epidemiol. 1990 Oct;4(4):373–381. [PubMed]
  • Newacheck PW, Halfon N. The association between mother's and children's use of physician services. Med Care. 1986 Jan;24(1):30–38. [PubMed]
  • Freed GL, Clark SJ, Pathman DE, Schectman R. Influences on the receipt of well-child visits in the first two years of life. Pediatrics. 1999 Apr;103(4 Pt 2):864–869. [PubMed]
  • Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer CJ. Infant health care use and maternal depression. Arch Pediatr Adolesc Med. 1999 Aug;153(8):808–813. [PubMed]
  • Suarez L, Simpson DM, Smith DR. Errors and correlates in parental recall of child immunizations: effects on vaccination coverage estimates. Pediatrics. 1997 May;99(5):E3–E3. [PubMed]
  • Bates AS, Fitzgerald JF, Dittus RS, Wolinsky FD. Risk factors for underimmunization in poor urban infants. JAMA. 1994 Oct 12;272(14):1105–1110. [PubMed]
  • Gavin NI, Adams EK, Herz EJ, Chawla AJ, Ellwood MR, Hill IT, Zimmerman BL, Wasserman J. The use of EPSDT and other health care services by children enrolled in Medicaid: the impact of OBRA'89. Milbank Q. 1998;76(2):207–250. [PMC free article] [PubMed]

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