Adverse Childhood Experiences and Healthcare Utilization Among Racially and Ethnically Minoritized Children: A Systematic Review

Background and Purpose: Racially and ethnically minoritized children often experience a higher prevalence of Adverse Childhood Experiences (ACEs), yet the relationship between ACEs and healthcare utilization remains poorly understood and inconsistent. This review aims to address this gap by critically evaluating studies published after 2014, following the full implementation of the Affordable Care Act, to explore how ACEs are associated with healthcare utilization among minoritized children. Given the pivotal role of socioeconomic factors and health insurance in access to care, examining this association in the existing literature is crucial in informing evidence-based practice and policy decisions to reduce health disparities among marginalized children.

Methods: Following the CIMOST framework, inclusion criteria were specified as follows: (1) report on a defined sample of racially and ethnically minoritized groups or include a stratified subsample. In the current review, racially and ethnically minoritized children are defined as those who identify as Black, African American, American Indian, Alaska Native, Asian, Native Hawaiian, Pacific Islander, multi-racial, mixed race, Hispanic, or Latinx; (2) report ACEs; (3) examine formal healthcare utilization as an outcome; (4) report both socioeconomic status and health insurance-related characteristics; (5) empirical observational studies; (6) published in peer-reviewed journals; (7) having publication dates from 2014 onwards; (8) English language publication. In June 2023, a comprehensive keyword search was conducted on CINAHL, MEDLINE, PsycINFO, and PubMed. The PRISMA framework guided the screening process through title/abstract and full-text screenings. The quality of the studies was assessed using the JBI critical appraisal tool.

Results: Of 1,335 studies, a total of nine quantitative studies were included in the final review. ACEs were commonly operationalized as a categorical variable derived from summed total scores (n = 5). Some of the studies utilized the original 10-item ACEs questionnaires consisting of childhood abuse and neglect and household dysfunction domains (n = 4), while others focused on certain areas of ACEs or adapted versions (n = 5). Healthcare utilization was operationalized as a binary variable in most of the studies (n = 8) and a total of 12 types of healthcare services, encompassing preventive and emergency care, were addressed in the included studies. ACEs were associated with higher emergency care use delayed or forgone care and lower preventive care use. Racially and ethnically minoritized children had lower odds of receiving care and higher odds of delayed or forgone care, not receiving needed care, across various healthcare services. Disparities in healthcare utilization based on income and insurance status were identified.

Conclusions and Implications: These findings highlight the pressing need for targeted early interventions for racially and ethnically minoritized children aiming to reduce financial barriers and promote routine care utilization instead of emergency care use. Future research should employ comprehensive ACEs measures encompassing community-level ACEs and experiences of racial discrimination. Also, healthcare utilization outcomes should be operationalized that incorporate the duration, severity, and frequency of the service use. It is essential to embed considerations for racial equity throughout the research process to address structural inequities, moving beyond acknowledging the differences between the groups.