Pediatric obstructive sleep APNEA (OSA) is a grave condition that may have lasting neurodevelopmental and health outcomes if left untreated (Stepanski et al., 1999; Huang and Guilleminault, 2017; Gouthro and Slowik, 2022). Poor academic performance, neurobehavioral impairment, and reduced quality of life are consistently associated with untreated OSA (Spilsbury et al., 2006; Strocker and Shapiro, 2007; Capdevila et al., 2008). Early diagnosis and treatment are crucial to circumvent poor child development outcomes. The path to OSA detection often varies; for example, the process can be initiated by parent concerns, provider screening, or as an incidental finding (Honaker et al., 2022). We posit that this path is influenced by parent experiences that are shaped by race.

While OSA affects up to 5% of American children, black children are 2–4 times more likely to experience OSA compared to white children (Levers-Landis and Redline, 2007; Paruthi, 2022). Evidence suggests that median time to diagnosis can be up to five times longer among black children compared to their white counterparts (Kilaikode et al., 2018). Delayed diagnosis may contribute to broader disparities in health and academic functioning.

The literature identifies race and socio-economic status (SES) as key risk factors associated with pediatric sleep disparities. The previous paragraph highlights the association between minority race and greater OSA risk/delayed detection (Stamatakis et al., 2007; Giddens et al., 2022). In addition, research shows that lower SES, as measured by income and education, is linked to sleep disparities and OSA risk over the life course, even when controlling for race (Spilsbury et al., 2006; Xie et al., 2018). For example, Spilsbury et al. (2006) found that primary caregiver education and other components of neighborhood disadvantage were associated with pediatric OSA severity and diagnosis, particularly among African–American children. Xie et al. (2018) identified single-parent households, public insurance, and proximity to care centers as factors affecting OSA health outcomes. The interaction between SES and race is likely to amplify the risk for OSA and delayed diagnosis in black children with lower SES. Family support is identified as a positive determinant of OSA patient outcomes and could be a key factor in the detection and treatment of OSA in disadvantaged populations (Luyster et al., 2016). It is important to consider both race and SES in addressing pediatric sleep disparities and improving detection and treatment of OSA, especially among historically disadvantaged black populations (Danielson, 2022; Park et al., 2022). Given that race is a social construct influenced by historical and contemporary manifestations of structural racism, it is important to examine how parents' race may affect their OSA detection journey experience (e.g., interactions with the education or healthcare system).

In our previous work, we described parental experiences with OSA detection in their child via qualitative analysis of interviews with a diverse sample of parents. For example, we found that parents had varying experiences during their OSA detection process in their children, which highlighted a need for dissemination of accurate OSA information targeting parents, as well as systemic strategies between medical providers, schools and parents that can lead to earlier detection (Honaker et al., 2022). Missing from the literature, however, are studies examining the role of race in parental experience with pediatric OSA detection. Thus, our objective was to examine shared and unique parental experiences with pediatric OSA detection in black and white parents.

To our knowledge, this is the first qualitative study to examine parental experiences with pediatric OSA detection by race. Racial differences were identified in the path to child OSA diagnosis. As all parents in the study had children with Medicaid insurance, differences were likely driven primarily by racial factors and not socioeconomic status. Negative parent experiences due to bias or interactions with the school system may be an indication of racism and health disparities. For example, Misplaced Blame was a divergent theme only reported by Black mothers. One Black mother described her perception of being blamed for her child's sleepiness “The school was always—when they brought him home, they were always telling me he was sleeping at school. I'm like okay, I kind of know why he's sleeping. You all are saying it like I just don't put him to bed on time or something.” (ID3). Similarly, another Black mother stated, “She would fall asleep more than once, and so I had told the teacher, I said she goes to bed on time, at a decent time.” (ID1). The lack of OSA awareness among both the teacher and mother may be at play during early stages of the detection process. The negative parent-teacher interactions associated with parent blame may feel more pronounced among a minoritized population.

The divergent themes, “It Takes a Village—Teacher, and Trust in Provider,” illustrate the influential role of each adult in a child's life on the pathway to OSA detection, particularly for Black children. There is a critical need for teacher OSA awareness and understanding, that undiagnosed OSA may manifest as behavioral problems in the classroom. This gap in teacher understanding, and potential implicit bias, may set Black children on a negative academic trajectory (Chin et al., 2020). Undiagnosed sleep apnea may contribute to poor academic performance or learning challenges (Galland et al., 2015). These learning challenges, coupled with race, may hamper student achievement for Black children, given that teacher observations about child sleep health in the classroom may be a contributing factor to a child's academic trajectory (Ursache et al., 2021). In addition, Black mothers are likely to experience discrimination in the education system, while exhibiting agency in their parent advocacy for their child (Rall and Holman, 2021).

Teachers and providers are influential in facilitating parents to obtain a PSG for their child and educating parents along the way during the process. The themes Trust in Provider and Healthcare Provider as a Source of Knowledge were unique to, or more prevalent in, Black children. Additionally, the convergent theme of Healthcare Provider as a Source of Knowledge, more prominent among Black mothers than White mothers, reinforces the need to examine potential provider bias. Provider bias has been associated with negative attitudes toward Black people, that could lead to poor health outcomes for their child (Hall et al., 2015). In addition, parent's source of OSA knowledge may be most affected by their own childhood experiences or education from a provider. Healthcare providers may be a trusted source of health information among some Black adults (Swoboda et al., 2018), similar to the mothers in our study. Yet, establishing interpersonal trust in the patient-provider relationship may depend heavily on the degree of communication, technical competence, perceived quest for profit, and potential racism perceived by a Black patient (Jacobs et al., 2006). Providers caring for Black patients should examine their racial consciousness and consider how race may affect their interpersonal relationship.

While treatment guidelines recommend universal OSA screening (Marcus et al., 2012), in many cases the detection pathway is initiated by parents raising concerns to their child's provider. Considering themes related to parental knowledge about OSA, both Black and White mothers reported OSA knowledge gaps that may have delayed their child's path to detection. For example, Snoring is Normal and Missing the day-night Connection, were divergent themes among Black mothers. Normalized snoring and not connecting daytime and nighttime symptoms suggest a knowledge gap in Black mothers that could delay OSA detection. Similarly, OSA Knowledge—Dying in One's Sleep was a divergent theme among White mothers, indicating a clear lack of understanding of OSA consequences.

The clinical significance of this study is its potential to contribute to earlier screening, detection and treatment of obstructive sleep apnea, especially among minoritized Black children. Earlier detection rates hold the clinical significance for potentially earlier rates of diagnosis and treatment that could affect child development outcomes, and potentially reduce health disparity outcomes. Delayed detection and diagnoses of OSA among Black children and adults (Dudley and Patel, 2016), may contribute to higher severity of disease state, and poor child development outcomes. The experiences of families in our study are consistent with this disparity, as Black children were about 2 years older than White children on average at the time of diagnosis. This OSA disparity may be due to a combination of lack of awareness, knowledge gaps, and miscommunication by the healthcare system. For instance, one Black mother stated, “I just wish the primary care had gotten back with me. I'm not certain as to who was supposed to let me know. Like the ENT called and told me about the breathing part, but she was like that's all we know.” (ID7) Timeliness from detection to diagnosis, is of paramount importance given the developmental affect untreated OSA may have on a child's physical health and development. Additionally, there also may have been differences in how mothers interpreted and acted upon observed OSA symptoms. A convergent theme more prominent among White mothers was a perception that, Something is Wrong, and Is it Really Needed? These themes fall in contrast to each other, as one serves as a facilitator to detection, while the other one is a barrier. Black mothers were more likely to express, Wanting to Know what was wrong with their child as a PSG facilitator. Other convergent experiences around Worries, and Whatever It Takes, were reported among mothers from both racial groups. Black mothers were more likely to describe positive experiences about the Benefits of OSA Detection and Treatment,” highlighting the importance of timely detection in Black children.

There are both commonalities and differences on the OSA detection pathway for Black and White children and their parents. Differences in parent experiences are affected by individual awareness, education, patient-provider interactions, and experience with the school system that reflect bias. Parents and other adult figures in a child's life, such as school teacher or pediatrician, need targeted awareness of OSA and its behavioral and developmental consequences. Findings from this study are being applied toward the development of a health communication message to raise parental awareness about the signs and symptoms of OSA. In addition to raising awareness of OSA, structural changes are needed in the healthcare system to improve responsiveness and engagement with high-risk communities to reduce the effect of pediatric OSA disparities.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author/s.

The study was approved by the Indiana University School of Medicine Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.

SH provided substantial contributions to the conception, design, data analysis, and interpretation of data. AG contributed to the data analysis and interpretation of data. LF revised and edited the manuscript critically for intellectual content. AC drafted the work and contributed substantially to the manuscript conception, design, data analysis, and interpretation of data. All authors contributed to the article and approved the submitted version.