Elevated asthma and indoor environmental exposures among Puerto Rican children of East Harlem

Racial Inequities in Asthma Care

Racial inequities in asthma care are evolving as a recognized factor in long-standing inequities in asthma outcomes (e.g., hospitalization and mortality). Little research has been conducted regarding the presence or absence of racial inequities among patients seen in asthma specialist settings, this is an important area of future research given that asthma specialist care is recommended for patients experiencing the poor asthma outcomes disproportionately experienced by Black and Hispanic patients. This study provides a systematic review of racial asthma care inequities in asthma epidemiology, clinical assessment, medication prescription, and asthma specialist referral practices.

Housing environments and asthma outcomes within population-based samples of adults and children in NYC

Exposure to indoor environmental risk factors is associated with patterns of asthma morbidity. In this study, we assessed the relationship between housing type (i.e., home ownership, public housing, rental assistance, rent-controlled housing and other rental housing) and asthma outcomes among New York City (NYC) adults and children (ages 1-13). We used the 2019 NYC Community Health Survey (CHS) and 2019 NYC KIDS survey to analyze associations between housing type and ever having been diagnosed with asthma ("ever asthma") and experiencing a past-year asthma attack. We further examined whether associations were modified by smoking status (among adults), smoking within the home (among children), and overweight/obesity. Among adults, living in public housing, compared to home ownership, was associated with higher odds of ever asthma (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.35, 2.84), and past-year asthma attack (OR = 2.24; 95% CI 1.21,4.18). Living in rental assistance housing was also significantly associated with ever asthma (OR = 1.75; 95% CI 1.16, 2.66). Associations between public or rental assistance housing and ever asthma were marginally non-significant among children. Associations between living in public or rental assistance housing and ever asthma were more pronounced among ever smokers than among never smokers. Housing environments remain important predictors of both pediatric and adult asthma morbidity. Associations between living in subsidized housing and asthma outcomes among adults are most apparent among ever smokers.

Burden of allergic disease among ethnic minority groups in high-income countries

The COVID‐19 pandemic raised acute awareness regarding inequities and inequalities and poor clinical outcomes amongst ethnic minority groups. Studies carried out in North America, the UK and Australia have shown a relatively high burden of asthma and allergies amongst ethnic minority groups. The precise reasons underpinning the high disease burden are not well understood, but it is likely that this involves complex gene–environment interaction, behavioural and cultural elements. Poor clinical outcomes have been related to multiple factors including access to health care, engagement with healthcare professionals and concordance with advice which are affected by deprivation, literacy, cultural norms and health beliefs. It is unclear at present if allergic conditions are intrinsically more severe amongst patients from ethnic minority groups. Most evidence shaping our understanding of disease pathogenesis and clinical management is biased towards data generated from white population resident in high‐income countries. In conjunction with standards of care, it is prudent that a multi‐pronged approach towards provision of composite, culturally tailored, supportive interventions targeting demographic variables at the individual level is needed, but this requires further research and validation. In this narrative review, we provide an overview of epidemiology, sensitization patterns, poor clinical outcomes and possible factors underpinning these observations and highlight priority areas for research.

Cohort profile: Center for Research on Early Childhood Exposure and Development in Puerto Rico

PURPOSE

Puerto Rican children experience high rates of asthma and obesity. Further, infants born in Puerto Rico are more at risk for being born prematurely compared with infants on the mainland USA. Environmental exposures from multiple sources during critical periods of child development, potentially modified by psychosocial factors, may contribute to these adverse health outcomes. To date, most studies investigating the health effects of environmental factors on infant and child health have focused on single or individual exposures.

PARTICIPANTS

Infants currently in gestation whose mother is enrolled in Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) cohort, and infants and children already born to mothers who participated in the PROTECT study.

FINDINGS TO DATE

Data collection and processing remains ongoing. Demographic data have been collected on 437 mother-child pairs. Birth outcomes are available for 420 infants, neurodevelopmental outcomes have been collected on 319 children. Concentrations of parabens and phenols in maternal spot urine samples have been measured from 386 mothers. Center for Research on Early Childhood Exposure and Development mothers have significantly higher urinary concentrations of dichlorophenols, triclosan and triclocarban, but lower levels of several parabens compared with reference values from a similar population drawn from the National Health and Nutrition Examination Survey.

FUTURE PLANS

Data will continue to be collected through recruitment of new births with a target of 600 children. Seven scheduled follow-up visits with existing and new participants are planned. Further, our research team continues to work with healthcare providers, paediatricians and early intervention providers to support parent's ability to access early intervention services for participants.

Trends in Racial and Ethnic Disparities in Childhood Asthma in Miami, Florida: 2005-2013

Nationally, racial and ethnic disparities in childhood asthma plateaued from 2005 to 2013. We assessed trends in childhood asthma in Miami, Florida using Youth Risk Behavior Surveillance System (YRBSS) data and emergency department (ED) utilization and hospitalization rates by zip code population characteristics. Asthma prevalence in Miami did not vary significantly by race/ethnicity in YRBSS respondents in 2005 (16.2-17.2%, all groups), but rose in African-Americans and Hispanics and declined in Whites by 2013 to 27.9, 20.9 and 12.6%, respectively (P = 0.02). Median asthma ED visit rates rose from 106.8 (2006-2008) to 138.2 (2011-2013; P = 0.004) per 10,000 children. High-poverty and majority African-American zip codes were 6.3 and 7.3 times more likely to have asthma ED visit rates > 200 than others (P < 0.001). In high-poverty zip codes, majority African-American population was not associated with significantly higher ED utilization. In low-poverty zip codes, the association became stronger. Greater poverty explains much, but not all of Miami African-Americans' higher asthma risk.

Complex relationships between vitamin D and allergic sensitization among Puerto Rican 2-year-old children

BACKGROUND

In the United States, Puerto Ricans have a higher prevalence of asthma than other Latino ethnicities. Low vitamin D levels for children living in northern climates could be a factor.

OBJECTIVE

To assess serum 25-hydroxyvitamin D [25(OH)D] distributions (a marker of vitamin D) and associations among vitamin D, allergic sensitization, early wheeze, and home/demographic factors.

METHODS

Puerto Rican infants born in New York City, with a maternal history of atopy, were enrolled in a birth cohort. Blood was collected at age 2 years (n = 154; 82 males and 72 females). Serum 25(OH)D and immunoglobulin E (IgE) (indoor allergen-specific and total) were determined using immunoassays. Home/demographic characteristics and respiratory symptoms were assessed by questionnaire.

RESULTS

The median concentration of 25(OH)D was 22.6 ng/mL; 32% were at risk of deficiency or inadequacy (<12 or 12-19 ng/mL). Serum 25(OH)D levels were lower in the heating (a surrogate for less sun exposure in colder months) compared with nonheating (26.1 vs 22.7 ng/mL, P = .02) season, but were not associated with allergen-specific IgE levels or with level of acculturation (measured by maternal birthplace). However, low 25(OH)D levels (below median) were associated with high total IgE >100 IU/mL (P = .01). Also, 25(OH)D concentrations differed between children who attended daycare and those who did not (21.8 vs 24.5 ng/mL; t test, P = .02). Serum 25(OH)D was not associated with wheeze or asthma by 2 years of age (P = .43).

CONCLUSION

Vitamin D deficiency, possibly linked with allergic pathways, may partially explain the trajectory for disproportionate asthma burden among Puerto Ricans, especially those born and raised in colder climates.

Subsidized Housing and Adult Asthma in Boston, 2010-2015

OBJECTIVES

To examine whether subsidized housing, specifically public housing and rental assistance, is associated with asthma in the Boston, Massachusetts, adult population.

METHODS

We analyzed a pooled cross-sectional sample of 9554 adults taking part in 3 Boston Behavioral Risk Factor Surveillance System surveys from 2010 to 2015. We estimated odds ratios for current asthma in association with housing status (public housing development [PHD] resident, rental assistance [RA] renter, non-RA renter, nonrenter nonowner, homeowner as reference) in logistic regression analyses adjusting for year, age, sex, race/ethnicity, education, and income.

RESULTS

The odds of current asthma were 2.02 (95% confidence interval [CI] = 1.35, 3.03) and 2.34 (95% CI = 1.60, 3.44) times higher among PHD residents and RA renters, respectively, than among homeowners. We observed smoking-related effect modification (interaction P = .04); elevated associations for PHD residents and RA renters remained statistically significant (P < .05) only among ever smokers. Associations for PHD residents and RA renters remained consistent in magnitude in comparison with non-RA renters who were eligible for subsidized housing according to income.

CONCLUSIONS

Public housing and rental assistance were strongly associated with asthma in this large cross-sectional sample of adult Boston residents.

At-risk children with asthma (ARC): a systematic review

Introduction

Asthma attacks are responsible for considerable morbidity and may be fatal. We aimed to identify and weight risk factors for asthma attacks in children (5–12 years) in order to inform and prioritise care.

Methods

We systematically searched six databases (May 2016; updated with forward citations January 2017) with no language/date restrictions. Two reviewers independently selected studies for inclusion, assessed study quality and extracted data. Heterogeneity precluded meta-analysis. Weighting was undertaken by an Expert Panel who independently assessed each variable for degree of risk and confidence in the assessment (based on study quality and size, effect sizes, biological plausibility and consistency of results) and then achieved consensus by discussion. Assessments were finally presented, discussed and agreed at a multidisciplinary workshop.

Results

From 16 109 records, we included 68 papers (28 cohort; 4 case-control; 36 cross-sectional studies). Previous asthma attacks were associated with greatly increased risk of attack (ORs between 2.0 and 4.1). Persistent symptoms (ORs between 1.4 and 7.8) and poor access to care (ORs between 1.2 and 2.3) were associated with moderately/greatly increased risk. A moderately increased risk was associated with suboptimal drug regimen, comorbid atopic/allergic disease, African-American ethnicity (USA), poverty and vitamin D deficiency. Environmental tobacco smoke exposure, younger age, obesity and low parental education were associated with slightly increased risk.

Discussion

Assessment of the clinical and demographic features identified in this review may help clinicians to focus risk reduction management on the high-risk child. Population level factors may be used by health service planners and policymakers to target healthcare initiatives.

Trial registration number

CRD42016037464.

Effect of aging on sputum inflammation and asthma control

BACKGROUND

Aged asthmatic patients experience increased morbidity and mortality. Knowledge of the aging effect on airway inflammation and asthma control is limited.

OBJECTIVE

We sought to compare airway inflammation and its relationship to asthma control in aged versus younger patients and determine whether differences are asthma specific or caused by "inflamm-aging."

METHODS

We performed a prospective study of aged (>60 years) and younger (21-40 years) inner-city patients with asthma. After a run-in period to control for inhaled corticosteroid use, induced sputum was collected. Age-matched nonasthmatic control subjects were included to measure age-related inflammatory changes.

RESULTS

Aged (mean age, 67.9 ± 5.1 years; n = 35) compared with younger (mean age, 30.8 ± 5.9 years; n = 37) asthmatic patients had significantly worse asthma control and lower FEV₁. Aged asthmatic patients had higher sputum neutrophil (30.5 × 10⁴/mL and 23.1%) and eosinophil (7.0 × 10⁴/mL and 3.8%) numbers and percentages compared with younger patients (neutrophils, 13.0 × 10⁴/mL [P < .01] and 6.9% [P < .01]; eosinophils, 2.0 × 10⁴/mL [P < .01] and 1.2% [P < .01]). Aged asthmatic patients had higher sputum IL-6 (P < .01) and IL-8 (P = .01) levels. No significant inflammatory differences between aged and younger control subjects were observed. In aged asthmatic patients increased sputum IL-6 and macrophage inflammatory protein 3α/CCL20 levels were significantly associated with decreased asthma control and increased sputum neutrophil numbers and IL-1β, IL-6, and macrophage inflammatory protein 3α/CCL20 levels were associated with hospitalization.

CONCLUSIONS

The inflammatory patterns of aged versus younger asthmatic patients are associated with increased sputum neutrophil and eosinophil values and cytokine levels related to neutrophil recruitment. Differences in airway inflammation can contribute to diminished asthma control in the aged. Further understanding of asthma pathophysiology in aged patients is needed to improve management of this vulnerable population.

Sensitization to mouse and cockroach allergens and asthma morbidity in urban minority youth: Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II)

BACKGROUND

Pest allergen sensitization is associated with asthma morbidity in urban youth but minimally explored in Latino populations. Specifically, the effect of mouse sensitization on the risk of asthma exacerbation has been unexplored in Latino subgroups.

OBJECTIVE

To evaluate whether pest allergen sensitization is a predictor of asthma exacerbations and poor asthma control in urban minority children with asthma.

METHODS

Latino and African American children (8-21 years old) with asthma were recruited from 4 sites across the United States. Logistic regression models evaluated the association of mouse or cockroach sensitization with asthma-related acute care visits or hospitalizations.

RESULTS

A total of 1,992 children with asthma in the Genes-environments and Admixture in Latino American (GALA-II) and Study of African-Americans, Asthma, Genes, and Environments (SAGE-II) cohorts were studied. Asthmatic children from New York had the highest rate of pest allergen sensitization (42% mouse, 56% cockroach), with the lowest rate in San Francisco (4% mouse, 8% cockroach). Mouse sensitization, more than cockroach, was associated with increased odds of acute care visits (adjusted odds ratio [aOR], 1.47; 95% CI, 1.07-2.03) or hospitalizations (aOR, 3.07; 95% CI, 1.81-5.18), even after controlling for self-reported race and site of recruitment. In stratified analyses, Mexican youth sensitized to mouse allergen did not have higher odds of asthma exacerbation. Other Latino and Puerto Rican youth sensitized to mouse had higher odds of hospitalization for asthma (aORs, 4.57 [95% CI, 1.86-11.22] and 10.01 [95% CI, 1.77-56.6], respectively) but not emergency department visits.

CONCLUSION

Pest allergen sensitization is associated with a higher odds of asthma exacerbations in urban minority youth. Puerto Rican and Other Latino youth sensitized to mouse were more likely to have asthma-related hospitalizations than Mexican youth.

Effectiveness of a multi-level asthma intervention in increasing controller medication use: a randomized control trial

INTRODUCTION

Poor self-management by families is an important factor in explaining high rates of asthma morbidity in Puerto Rico, and for this reason we previously tested a family intervention called CALMA that was found effective in improving most asthma outcomes, but not effective in increasing the use of controller medications. CALMA-plus was developed to address this issue by adding to CALMA, components of provider training and screening for asthma in clinics.

METHODS

Study participants were selected from claims Medicaid data in San Juan, Puerto Rico. After screening, 404 children in eight clinics were selected after forming pairs of clinics and randomizing the clinics) to CALMA-only or CALMA-plus.

RESULTS

For all three primary outcomes at 12 months, the mean differences between treatment arms were small but in the predicted direction. However, after adjusting for clinic variation, the study failed to demonstrate that the CALMA-plus intervention was more efficacious than the CALMA-only intervention for increasing controller medication use, or decreasing asthma symptoms. Both groups had lower rates of asthma symptoms and service utilization, consistent with previous results of the CALMA-only intervention.

CONCLUSIONS

Compliance of providers with the intervention and training, small number of clinics available and the multiple barriers experienced by providers for medicating may have been related to the lack of difference observed between the groups. Future interventions should respond to the limitations of the present study design and provide more resources to providers that will increase provider participation in training and implementation of the intervention.

Clinical Interventions to Promote Breastfeeding by Latinas: A Meta-analysis

CONTEXT

Breastfeeding duration and exclusivity among Latinas fall below recommended levels, indicating a need for targeted interventions. The effectiveness of clinical breastfeeding interventions for Latinas remains unclear.

OBJECTIVE

To systematically review the documented effectiveness of clinical breastfeeding interventions on any and exclusive breastfeeding among Latinas.

DATA SOURCES

English-language publications in Medline, CINAHL, and Embase were searched through May 28, 2015.

STUDY SELECTION

Fourteen prospective, controlled studies describing 17 interventions met inclusion criteria.

DATA EXTRACTION

Extracted study characteristics include study design, population characteristics, intervention components, timing and intensity of delivery, provider type, control procedures, and outcome measures.

RESULTS

Random-effects meta-analyses estimated risk differences (RDs) between breastfeeding mothers in intervention and control arms of each study and 95% prediction intervals (PIs) within which 95% of intervals cover the true value estimated by a future study. Interventions increased any breastfeeding at 1 to 3 and 4 to 6 months (RD 0.04 [95% PI -0.15 to 0.23] and 0.08 [-0.08 to 0.25], respectively) and exclusive breastfeeding at 1 to 3 and 4 to 6 months (0.04 [-0.09 to 0.18] and 0.01 [-0.01 to 0.02]). Funnel plot asymmetry suggested publication bias for initiation and 1- to 3-month any breastfeeding. Estimates were slightly larger among interventions with prenatal and postpartum components, 3 to 6 patient contacts, and delivery by an International Board Certified Lactation Consultant or lay provider.

LIMITATIONS

The published evidence for Latinas is limited, and studies have varying methodologic rigor.

CONCLUSIONS

Breastfeeding interventions targeting Latinas increased any and exclusive breastfeeding compared with usual care.

Increasing participation in genomic research and biobanking through community-based capacity building

Achieving equitable minority representation in genomic biobanking is one of the most difficult challenges faced by researchers today. Capacity building--a framework for research that includes collaborations and on-going engagement--can be used to help researchers, clinicians and communities better understand the process, utility, and clinical application of genomic science. The purpose of this exploratory descriptive study was to examine factors that influence the decision to participate in genomic research, and identify essential components of capacity building with a community at risk of being under-represented in biobanks. Results of focus groups conducted in Central Harlem with 46 participants were analyzed by a collaborative team of community and academic investigators using content analysis and AtlisTi. Key themes identified were: (1) the potential contribution of biobanking to individual and community health, for example the effect of the environment on health, (2) the societal context of the science, such as DNA criminal databases and paternity testing, that may affect the decision to participate, and (3) the researchers' commitment to community health as an outcome of capacity building. These key factors can contribute to achieving equity in biobank participation, and guide genetic specialists in biobank planning and implementation.

Associations of neighborhood concentrated poverty, neighborhood racial/ethnic composition, and indoor allergen exposures: a cross-sectional analysis of los angeles households, 2006-2008

Although racial/ethnic, socioeconomic, and neighborhood factors have been linked to asthma, and the association between indoor allergens and asthma is well documented, few studies have examined the relationship between these factors and indoor allergens. We examined the frequency of reported indoor allergens and differences by racial/ethnic, socioeconomic, and neighborhood characteristics among a diverse sample of Los Angeles households. Multilevel logistic regression models were used to analyze the data from 723 households from wave 2 of the Los Angeles Family and Neighborhood Survey. The reported presence of rats, mice, cockroaches, mold, pets, and tobacco smoke were the primary outcomes of interest. Hispanic and Asian households had a nearly threefold increase in the odds of reporting cockroaches compared to non-Hispanic Whites (OR, 2.85; 95 % CI 1.38-5.88 and OR, 2.62; 95 % CI 1.02-6.73, respectively) even after adjusting for socioeconomic factors. Primary caregivers who had obtained a high school degree were significantly less likely to report the presence of mice and cockroaches compared to primary caregivers with less than a high school degree (OR, 0.19; 95 % CI 0.08-0.46 and OR, 0.39; 95 % CI 0.23-0.68, respectively). Primary caregivers with more than a high school degree were also less likely to report the presence of rats, mice, and cockroaches within their households, compared to those with less than a high school degree. Compared to renters, home owners were less likely to report the presence of mice, cockroaches, and mold within their households. At the neighborhood level, households located within neighborhoods of high concentrated poverty (where the average poverty rate is at least 50 %) were more likely to report the presence of mice and cockroaches compared to households in low concentrated poverty neighborhoods (average poverty rate is 10 % or less), after adjusting for individual race/ethnicity and socioeconomic characteristics. Our study found evidence in support of neighborhood-level racial/ethnic and socioeconomic influences on indoor allergen exposure, above and beyond individual factors. Future studies should continue to explore individual and neighborhood-level racial/ethnic and socioeconomic differences in household allergen exposures across diverse contexts.

Home asthma triggers: barriers to asthma control in Chicago Puerto Rican children

We sought objectively to measure, summarize, and contextualize the asthma triggers found in the homes of urban high-risk Puerto Rican children and adolescents with asthma in Chicago. Data were from the baseline home assessments of Project CURA. Research assistants interviewed caregivers, conducted a home visual inspection, and collected saliva samples for cotinine analysis. A trigger behavior summary score was created. The housing inspected was old with multiple units and obvious structural deficiencies. Many allergic and irritant triggers were observed. Having a controller medicine or private insurance was associated with lower trigger behavior summary scores; caregiver depression, caregiver perceived stress, and child negative life events were associated with high trigger scores. The final multivariate model retained had a controller medicine, private insurance, and caregiver perceived stress. The data from this high-risk cohort identified modifiable areas where environmental interventions could reduce morbidity in Puerto Rican children and adolescents.

Examining household asthma management behavior through a microeconomic framework

National guidelines on the effective management of pediatric asthma have been promoted for over 20 years, yet asthma-related morbidity among low-income children remains disproportionately high. To date, household and clinical interventions designed to remediate these differences have been informed largely by a health behavior framework. However, these programs have not resulted in consistent sustained improvements in targeted populations. The continued funding and implementation of programs based on the health behavior framework leads us to question if traditional behavioral models are sufficient to understand and promote adaptation of positive health management behaviors. We introduce the application of the microeconomic framework to investigate potential mechanisms that can lead to positive management behaviors to improve asthma-related morbidity. We provide examples from the literature on health production, preferences, trade-offs and time horizons to illustrate how economic constructs can potentially add to understanding of disease management. The economic framework, which can be empirically observed, tested, and quantified, can explicate the engagement in household-level activities that would affect health and well-being. The inclusion of a microeconomic perspective in intervention research may lead to identification of mechanisms that lead to household decisions with regard to asthma management strategies and behavior. The inclusion of the microeconomic framework to understand the production of health may provide a novel theoretical framework to investigate the underlying causal behavioral mechanisms related to asthma management and control. Adaptation of an economic perspective may provide new insight into the design and implementation of interventions to improve asthma-related morbidity in susceptible populations.

Asthma, tobacco smoke and the indoor environment: a qualitative study of sheltered homeless families

OBJECTIVE

Asthma is common in homeless children with an incidence of 28-40%. There are few published studies investigating asthma in homeless children. This study examines the perspectives of both caregivers and shelter staff regarding challenges and opportunities of caring for children with asthma.

METHODS

A focus group of sheltered parents (n = 10) with children who have asthma was conducted to identify barriers to optimal asthma management. Key informant interviews (n = 6) were conducted with shelter staff to discuss the shelter systems and policies to address childhood asthma. Data were audio-recorded and transcribed. A representative analysis team performed qualitative theme analysis.

RESULTS

Key themes across 5 domains were identified: asthma education, access to asthma medication and equipment, asthma action plans, structural barriers to asthma management and environmental triggers. Parents identified multiple asthma triggers present in the shelter environment but cited lack of control as a barrier to remediation. Shelter staff desired elimination of asthma triggers but refer to the lack of resources as the primary barrier. Shelter staff favored a smoking ban on shelter property but named challenges to policy implementation. Both parents and staff identified asthma education and increased access to medications would be helpful.

CONCLUSIONS

Policies to reduce environmental exposures, such as a smoking ban, to asthma triggers has the potential to improve the health of sheltered children with asthma.

Asthma and physical activity in multiracial girls from three US sites

OBJECTIVE

Studies comparing physical activity levels in children with and without asthma have had mixed results. Our objective was to investigate the association between asthma diagnosis and physical activity and to examine differences in these associations by race/ethnicity, weight status and caregiver education.

METHODS

We investigated the association between asthma (defined as report of physician-diagnosed asthma with at least one asthma related symptom) and measures of physical and sedentary activity in a study of 6- to 8-year-old girls in the Breast Cancer and the Environment Research Project. We compared reported activity and pedometer measurements among girls with and without asthma, and examined modification of these associations by race/ethnicity, weight status and caregiver education.

RESULTS

Girls (n = 1182) were included with 33.5% White, 4.8% Asian, 30.6% non Hispanic Black and 30.7% Hispanic. Asthma was present in 16.2% of girls. Overall, 38% of girls reported no participation in organized recreational activities and 58% had >2 h/day of television, video game and computer time combined. Girls with asthma whose parents were less educated reported fewer pedometer steps and less non-scheduled activity than girls without asthma with similar caregiver education level. Among girls with asthma, those on a controller medication had higher levels of sedentary activity and more structured physical activity but were less likely to report high intensity physical activity.

CONCLUSIONS

Among girls whose parents are less educated, girls with asthma may have lower physical activity levels than girls without asthma. Use of a controller medication may be related to physical and sedentary activity.

A review of barriers to effective asthma management in Puerto Ricans: cultural, healthcare system and pharmacogenomic issues

BACKGROUND

Among the Hispanic community, Puerto Ricans have the highest prevalence of asthma and manifest the worst outcomes. The expected growth of the Hispanic population in the USA in the next several decades make elimination of disparate care in Puerto Rican asthmatics a matter of national importance. The purpose of this review of the literature (ROL) is to examine a variety of health system, genetic and cultural barriers in the Puerto Rican community which have created disparities in asthma care and outcomes among adult and pediatric Hispanic populations. In addition, this ROL describes several culturally sensitive, community-based educational interventions which can be used as a framework for future projects to improved asthma outcomes.

METHODS

Databases searched included Medline, PubMED, EBSCOhost, PsycINFO, CINAHL, Google Scholar and ERIC. Papers published in English from January 1990 to January 2012 were reviewed.

RESULTS

Health system policies, insurer compensation patterns, clinician attitudes and cultural values/folk remedies in the Puerto Rican community represent barriers to effective asthma management, the use of controller medication and the implementation of educational interventions. In addition, genetic factors involving the beta-2 adrenergic receptor gene, which impair the response to albuterol, appear to contribute to poorer outcomes in Puerto Rican asthmatics. In contrast, several comprehensive, community-based, culturally sensitive educational interventions such as Controlling Asthma in American Cities Project (CAACP), the Racial and Ethnic Approach to Community Health in the US Program and Healthy Hoops programs (REACH) have been described.

CONCLUSIONS

We believe that culturally sensitive community-based asthma education programs can serve as models for programs targeted toward Puerto Ricans to help decrease asthma morbidity. Moreover, greater sensitivity to Puerto Rican mores and folk remedies on the part of healthcare providers may improve the patient-clinician rapport and, hence, asthma outcomes. Finally, given ethnically based differences in pharmacogenomics, clinical trials targeting the Puerto Rican population may help to better define optimal asthma medication regimens in this ethnic group.

Asthma in underserved schoolchildren in Miami, Florida: results of a school- and community-based needs assessment

OBJECTIVE

Asthma is the most common chronic condition in childhood and disproportionately impacts the poorer and ethnic minorities. The objectives of the study were to estimate the prevalence of asthma in Miami-Dade County (MDC) schoolchildren to aid case-finding and linkage to care.

METHODS

We used the CDC Youth Risk Behavior Surveillance System (YRBSS) definition of possible asthma ("Ever told by a doctor or nurse that they had asthma and still had asthma") and analyzed data from four sources. These included the: (1)-MDC YRBSS 2009, (2)-MDC Health Connect Asthma Survey of school nurses (>2008), (3)-parents' survey in the five HealthConnect survey elementary schools with highest asthma prevalence, and (4)-focus group with parents of asthmatic children.

RESULTS

(1)-MDC YRBSS data showed that 21.3% of high- and 21.4% of middle-school students had been diagnosed with possible asthma. Prevalence was the highest in African-American middle-school girls (26.9%). (2)-HealthConnect survey responders reported that 4.9% of the students in 131 MDC schools had possible asthma. Asthma prevalence was higher in elementary schools (median = 7.1%) and in low-income MDC zip codes. (3)-Of the parent survey responders, 24.9% indicated that their child had possible asthma, and 19.2% reported that their children had no usual source of care. (4)-Focus group participants reported frequent loss of Medicaid coverage for their children, landlords' indifference to the role of poorly maintained housing in asthma, and unmet needs regarding knowledge of health system navigation.

CONCLUSIONS

Asthma may be common in MDC schoolchildren, particularly in poor communities. Formidable structural factors limit the caregivers' abilities to manage childhood asthma.

The association between parental perception of neighborhood safety and asthma diagnosis in ethnic minority urban children

Low-income populations, minorities, and children living in inner cities have high rates of asthma. Recent studies have emphasized the role of psychosocial stress in development of asthma. Residence in unsafe neighborhoods is one potential source of increased stress. The study objective was to examine the association between parental perception of neighborhood safety and asthma diagnosis among inner city, minority children. Cross-sectional data from a community-based study of 6-8-year-old New York City children were used. Asthma was defined as parental report of physician-diagnosed asthma and at least one asthma-related symptom. Parental perceptions of neighborhood safety were assessed with a questionnaire. Associations between perceived neighborhood safety and asthma were examined using chi-squared tests. Multivariate logistic regression analyses were then performed. Five hundred four children were included with 79% female, 26.5% non-Hispanic Black, and 73.5% Hispanic. Asthma was present in 23.8% of children. There was an inverse association between feeling safe walking in the neighborhood and asthma with 45.7% of parents of asthmatic children reporting they felt safe compared to 60.9% of parents of non-asthmatic children (p = 0.006). Fewer parents of asthmatic children than of non-asthmatic children reported that their neighborhood was safe from crime (21.7% versus 33.9%, p = 0.018). In multivariate analyses adjusting for race/ethnicity, age, gender, socioeconomic status, number of smokers in the home and breastfeeding history, parents reporting feeling unsafe walking in the neighborhood were more likely to have a child diagnosed with asthma (OR = 1.89, 95%CI 1.13-3.14). Psychosocial stressors such as living in unsafe neighborhoods may be associated with asthma diagnosis in urban ethnic minority children. Addressing the increased asthma burden in certain communities may require interventions to decrease urban stressors.

Do Puerto Rican youth with asthma and obesity have higher odds for mental health disorders?

BACKGROUND

Island Puerto Rican (PR) youth experience disproportionately high asthma and obesity rates compared with other racial/ethnic groups on the U.S. mainland. Previous research has demonstrated associations of chronic disease with psychiatric disorders.

OBJECTIVE

We examined the relationship among anxiety/depressive disorders, asthma, and obesity in an epidemiologic community sample of youth.

METHODS

The sample (n = 656) was derived from the second wave of an island-wide probabilistic representative household sample of PR youth stratified and based on whether or not they had a diagnosis of asthma and/or depressive/anxiety disorder. For this study, we used the subpopulation ages 10-19 years.

RESULTS

Asthma and obesity were significantly related to higher odds of depressive/anxiety disorders in youth. Obesity moderated the relationship between asthma attacks and depressive/anxiety disorders. The relationship between asthma attack and higher odds for depressive/anxiety disorders was only present in the non-obese group. Among the obese, females show a significant increase from 11% to 36% in the prevalence of anxiety/depressive disorders. Asthma and obesity were highly prevalent and a significant association was found between asthma attack and depressive/anxiety disorders. The effects of asthma and obesity were not additive; the prevalence for psychiatric disorder for those having both conditions did not increase above the prevalence associated having only one of the conditions.

CONCLUSIONS

Future studies should consider including longitudinal designs and examine the extent to which important variables not included in this study, such as body image dissatisfaction (particularly among females), teasing, and discrimination may moderate the relationship among obesity and depressive and anxiety disorders in youth.

Genetics and asthma disease susceptibility in the US Latino population

The US Latino population is heterogeneous with diversity in environmental exposures and socioeconomic status. Moreover, the US Hispanic population derives from numerous countries previously under Spanish rule, and many Hispanics have complex proportions of European, Native American, and African ancestry. Disparities in asthma severity and control are due to complex interactions between environmental exposures, socioeconomic factors, and genetic variations. In addition, diseases within the Latino community may also differ by country of origin. Although US Census data show low asthma rates in the Hispanic population as a whole, there is a lot of variability in the prevalence and morbidity of asthma, with a prevalence of 5.0% in Mexican Americans versus 17.0% in Puerto Ricans. The diversity and population admixture make the study of the genetics of asthma complex in Latino populations. However, an understanding of the genetics of asthma in all populations, including the Latino population, can enhance risk identification, help us to target pharmacological therapy, and guide environmental regulations, all of which can promote a reduction in health disparities. The inclusion of markers of ancestral diversity and the incorporation of techniques to adjust for stratification now make these studies feasible in complex populations, including the Latino population. To date, studies using linkage analyses, genome-wide associations, or candidate gene analyses have identified an association of asthma or asthma-related phenotypes with candidate genes, including interleukin 13, beta-2 adrenergic receptor, a disintegrin and metalloproteinase 33, orosomucoid 1-like 3, and thymic stromal lymphopoietin. As reviewed here, although these genes have been identified in diverse populations, limited studies have been performed in Latino populations, and they have had variable replication. There is a need for the development of registries with well-phenotyped pediatric and adult Latino populations and subgroups for inclusion in the rapidly expanding field of genetic studies, and these studies need to be used to reduce health disparities.

The role of caregiver major depression in the relationship between anxiety disorders and asthma attacks in island Puerto Rican youth and young adults

The goal of this study was to assess whether the association between asthma attacks and anxiety disorders in youth/young adults is reduced after adjusting for the caregivers' psychiatric disorders. An island-wide probability sample of 641 households in Puerto Rico with youth/young adults between ages 10 and 25 years participated along with their caregivers. The Diagnostic Interview Schedule for Children and the Composite International Diagnostic Interview were conducted to assess anxiety and depressive disorders. Youth/young adults with an anxiety disorder were more likely to have a lifetime history of asthma attacks versus youth/young adults without an anxiety disorder. Caregivers of participants with asthma attacks were more likely to have major depression than did the caregivers of participants without asthma attacks. The association between asthma attacks and anxiety disorders in youth was no longer significant after adjustment for caregiver major depression. It is important to consider the role of caregiver depression in asthma-anxiety comorbidity in youth/young adults.

Are building-level characteristics associated with indoor allergens in the household?

Building-level characteristics are structural factors largely beyond the control of those who live in them. We explored whether building-level characteristics and indoor allergens in the household are related. We examined the relationship between building-level characteristics and indoor allergens: dust mite, cat, cockroach, and mouse. Building-level characteristics measured were presence of pests (seeing cockroaches and rodents), building type (public housing, buildings zoned commercially and residentially, and building size), and building condition (building age and violations). Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 μg/g; cat: >1 μg/g; cockroach: >1 U/g; mouse: >1.6 μg/g. In fully adjusted linear analyses, neither dust mite nor cat allergen were statistically significantly associated with any building-level characteristics. Cockroach allergen was associated with the presence of cockroaches (2.07; 95% CI, 1.23, 3.49) and living in public housing (2.14; 95% CI, 1.07, 4.31). Mouse allergen was associated with the presence of rodents (1.70; 95% CI, 1.29, 2.23), and building size: living in a low-rise (<8 floors; 0.60; 95% CI, 0.42, 0.87) or high-rise (8 + floors; 0.50; 95% CI, 0.29, 0.88; compared with house/duplex). In fully adjusted logistic analyses, cat allergen was statistically significantly associated with living in a high-rise (6.29; 95% CI, 1.51, 26.21; compared with a house/duplex). Mouse allergen was associated with living in public housing (6.20; 95% CI, 1.01, 37.95) and building size: living in a low-rise (0.16; 95% CI, 0.05, 0.52) or high-rise (0.06; 95% CI, 0.01, 0.50; compared with a house/duplex). Issues concerning building size and public housing may be particularly critical factors in reducing asthma morbidity. We suggest that future research explore the possible improvement of these factors through changes to building code and violations adherence, design standards, and incentives for landlords.

Crime, neighborhood deprivation, and asthma: a GIS approach to define and assess neighborhoods

Exposure to neighborhood factors remains difficult to quantify when neighborhoods are often predefined and imprecisely measured. This study examines the association between neighborhood deprivation and participation in a community-based asthma case management (CM) program in Oakland, CA. We estimated neighborhoods by calculating walking distances of , and miles around each child's (n=2892) residence. The model assesses deprivation by the addition of weighted factors within a child's neighborhood-crime rates, alcohol outlets, and eight 2000 US Census characteristics. The results illustrate that neighborhood deprivation is weakly associated with greater levels of program participation, but neighborhood education level, measured by percentage of residents with less than a high school education, is strongly associated with greater program participation (OR: 4.43, 95% CI: [1.23, 15.99]). Neighborhood deprivation factors were significantly different between neighborhoods defined by walking distances and census blockgroups (Wilcoxon-signed rank test: p<0.05).

Measures of obesity associated with asthma diagnosis in ethnic minority children

Objective. The study objective was to examine relationships between different body size measurements and asthma in ethnic minority children. Methods. We used data from a community-based study of 505 children aged 6-to-8 years old to study the association of percent body fat, fat distribution, and BMI percentile with asthma diagnosis. Poisson regression models were used to compute prevalence ratios (PRs) for sex-specific quintiles of the body fat measures on the main outcome of asthma. Results. When comparing the highest quintile of each body fat measure to the combined lowest two quintiles, higher body mass index percentile, percent body fat, and waist circumference all were associated with a higher likelihood of physician-diagnosed asthma (PR = 1.63 (95% CI 1.12-2.39), 1.50 (95% CI 1.02-2.21), and 1.56 (95% CI 1.04-2.34), resp.). Conclusions. This study found a significant association between increased body size and asthma diagnosis, regardless of the measurement examined.

Teacher characteristics and knowledge of asthma

OBJECTIVES

We explored the characteristics of teachers and their knowledge of asthma and its management in elementary and middle-school classrooms.

DESIGN

Teachers completed the Georgia Public School Teachers' Asthma Knowledge and Perception Survey.

SAMPLE

The study sample consisted of 593 elementary (n=291) and middle-school teachers (n=302) from Georgia.

METHODS

Participants were asked to complete a survey on asthma knowledge. Data were analyzed to examine differences among elementary- and middle-school teachers, teachers' level of educational attainment, teachers' chronic medical condition, and teachers' asthma status.

RESULTS

Middle-school teachers were more knowledgeable about asthma than elementary teachers. No differences were found among teachers based on their level of educational attainment. Most teachers strongly agreed that asthma could not be cured, but managed. Teachers with chronic illnesses were more knowledgeable than those without a chronic illness and teachers who had asthma were the most knowledgeable about asthma and its management.

CONCLUSIONS

Teacher knowledge of asthma and its management was low among all teachers regardless of educational attainment, health status, or whether teachers taught at elementary or middle-school levels.

Ethnic differences in perception of lung function: a factor in pediatric asthma disparities?

RATIONALE

Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non-Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process.

OBJECTIVES

To determine (1) if differences exist between Latino and non-Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes.

METHODS

Five hundred and twelve children, aged 7-16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use.

MEASUREMENTS AND MAIN RESULTS

Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non-Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity.

CONCLUSIONS

Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non-Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.

Are neighborhood-level characteristics associated with indoor allergens in the household?

BACKGROUND

Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well studied. We defined neighborhoods as community districts determined by the New York City Department of City Planning.

OBJECTIVE

We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household.

METHODS

Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n = 261), we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1,000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates), and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 microg/g; cat: >1 microg/g; cockroach: >1 U/g; mouse: >1.6 microg/g.

RESULTS

Serious housing code violations were statistically significantly positively associated with dust mite, cat, and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78).

CONCLUSIONS

Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions.

Issues and methods in disparities research: the Rhode Island-Puerto Rico asthma center

BACKGROUND

Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research.

OBJECTIVES AND METHODS

This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island-Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research.

RESULTS

Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented.

CONCLUSIONS

Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them.

Mite sensitization among Latina women in New York, where dust-mite allergen levels are typically low

In New York (NY), Latinos often have greater asthma morbidity than other ethnicities, and dust-mite sensitization is common despite low allergen levels. We investigated mite allergen exposure and sensitization in atopic and/or asthmatic women, the majority being Puerto Rican. Women (n = 274) recruited for a birth cohort study were visited postnatally. Dust from their homes was analyzed for mite allergens (Der f 1, Der p 1, and Blo t 5). Serum was analyzed for total and allergen-specific IgE. Thirty-seven percent were sensitized to Dermatophagoides pteronyssinus, 34% to Dermatophagoides farinae, and 21% to Blomia tropicalis. Only 5% of NY homes had levels of Der f 1 >2 microg/g; none had Blo t 5 or Der p 1 above this level. Caribbean or Latin American birthplace (a proxy for childhood exposure) was not associated with mite sensitization. Sensitization to D. pteronyssinus and D. farinae was associated with a report of doctor-diagnosed asthma [Odds ratio (OR) = 3.27, P = 0.003; OR = 2.81, P = 0.010, respectively]; sensitization to any mite was associated with asthma medication use in the past 12 months (OR = 3.12, P = 0.004). These associations held even after adjustment for cockroach, mouse, and cat sensitization.

PRACTICAL IMPLICATIONS

Despite the low concentrations of mite allergen in our community, many of the women in the atopically enriched cohort were sensitized to mites, even Blomia tropicalis which is typically found only in tropical environments.

The experience of being an Asthma Amigo in a program to decrease asthma episodes in Hispanic children

Asthma is the most common chronic illness among Latino children in urban areas. It is especially problematic for schools serving low-income and minority populations. The purpose of this study was to describe the experience of being an Asthma Amigo, a community-based educator who delivered asthma education to a Hispanic community in a train-the-trainer educational model. Focus group process evaluation was used to assess participant experiences and program strengths and weaknesses. Findings suggested that being an Asthma Amigo helped in gaining entrée into the community and in spreading the message of asthma triggers and prevention.

Effectiveness of an asthma management program in reducing disparities in care in urban children

OBJECTIVE

To examine differences in the effectiveness of a program to reduce use of health care services in urban-dwelling black and Hispanic children as a way to understand the origins of disparities.

METHODS

We examined hospitalization rates, emergency department (ED) visits, outpatient visits (OPVs), and bronchodilator and inhaled corticosteroid (ICS) prescriptions in 2,362 children receiving Medicaid who were enrolled in an asthma management program (Easy Breathing) from June 1, 1998, through May 31, 2001. We used generalized estimating equations to fit multivariate marginal Poisson regression models, controlling for sex, ethnicity, asthma severity, and secular trends.

RESULTS

Hospitalization rates were high and decreased 53% for black children and 33% for Hispanic children after the intervention. The ED visits decreased for Hispanic children, and OPVs decreased for both black and Hispanic children after Easy Breathing. The ICS prescription rates increased, with a decrease in the bronchodilator to ICS ratio from 5.81 to 2.16 in black children and from 4.74 to 2.17 in Hispanic children. Hispanic children filled more prescriptions for bronchodilators and ICSs (odds ratio, 1.29; 95% confidence interval, 1.05-1.59; P = .01; and odds ratio, 1.55; 95% confidence interval, 1.14-2.11; P = .005; respectively) 3 and 12 months after Easy Breathing. Black children were more likely than Hispanic children not to fill any asthma prescription. A total of 12% of children filled no asthma prescriptions.

CONCLUSIONS

Hispanic children seek more medical services than black children, whereas black children fill fewer prescriptions for bronchodilators and ICSs than Hispanic children. Easy Breathing reduces overall hospitalizations and OPVs in black and Hispanic children and asthma-specific ED visits in Hispanic children; the benefits of Easy Breathing are different in Hispanic and black children.

Housing and health: intersection of poverty and environmental exposures

The importance of adequate housing for the maintenance of health and well-being has long been a topic of scientific and public health policy discussion, but the links remain elusive. Here we explore the role of the residential environment in the etiology of illness (specifically asthma) and the persistence of socioeconomic health disparities. Housing conditions, shaped by social forces, affect exposure to physical and chemical "toxicants," thereby translating social adversities into individual illness and population health disparities. We discuss the mediating role of housing in determining health outcomes at multiple levels (social-structural, neighborhood, and individual family). To date, little attention has been paid by most environmental health scientists to the social-structural conditions underlying gross inequities in the distribution of toxic exposures, with even less attention to the processes whereby these social conditions may directly affect susceptibility to the toxic exposures themselves. This chapter goes beyond traditional medical and environmental science models to incorporate a range of social and physical determinants of environmental pollutions, illustrating how these conditions result in health and illness. We focus here on childhood asthma as an example of a serious public health problem that has been associated with low income, minority status, and characteristics of the home environment. We end the chapter with a discussion of the environmental justice movement and the role of housing as a potential agent of change and focus of interventions aimed to reduce the harmful effects of environmental pollutants.

The New York City Puerto Rican asthma project: study design, methods, and baseline results

OBJECTIVE

We examined asthma risk factors among 274 Puerto Rican children born in New York to atopic mothers.

METHODS

We prospectively followed the cohort to measure aeroallergens in their homes and assess allergic sensitization. Baseline data are presented.

RESULTS

Maternal smoking was significantly higher among women born on the continental United States (25%) vs. those born elsewhere (11%). Cat ownership was more frequent among mainland-born women (15%) compared with those born in Puerto Rico (4%). While some aeroallergens were prevalent, few dust samples contained detectable dust mite allergens.

CONCLUSIONS

By following this cohort, we hope to identify the roles that socio-cultural factors play in the process of allergic sensitization.

Is the prevalence of asthma and related symptoms among Brazilian children related to socioeconomic status?

OBJECTIVE

To evaluate the relationship between socioeconomic status (SES) and the prevalence of asthma and related symptoms among Brazilian children.

METHODS

The International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire was applied to 23,457 six- to seven-year-old schoolchildren (SC) and 58,144 thirteen- to fourteen-year-old adolescents (AD) from 20 Brazilian cities. SES was evaluated by infant mortality index, poverty index, and average nominal income for people older than 10 years of age.

RESULTS

Current asthma ranged from 16.5% to 31.2% among SC and from 11.8% to 30.5% among AD and severe asthma from 2.9% to 8.5% (SC) and 2.6% to 9.1% (AD). Higher values were observed in Brazilian-Northern, -Northeastern and -Southeastern centers. No significant association between SES and prevalence of asthma and related symptoms was observed.

CONCLUSIONS

In Brazil, the prevalence of asthma and related symptoms is quite variable and independent of SES.

The environmental health of Latino children

Representing 1 in 6 children in the United States, Latino children incur disproportionate exposures to air pollutants, pesticides, and toxic industrial chemicals, as well as lead and mercury from candy, traditional folk remedies, religious practices, and other sources. Latino children also have higher rates of asthma, lead and mercury poisoning, behavioral and developmental disorders, and certain cancers. Concurrent exposure to multiple pollutants, pre-existing disease, poor nutrition, substandard housing, limited access to health care, and other factors related to their lower socioeconomic status increase Latino children's susceptibility to environmental contaminants. Targeted research, education, prevention and intervention efforts, and economic development initiatives are needed.

Lack of association between indoor allergen sensitization and asthma morbidity in inner-city adults

BACKGROUND

Sensitivity and exposure to indoor allergens is associated with increased asthma morbidity in inner-city children. However, it is unknown whether sensitization is associated with worse asthma in adults.

OBJECTIVE

To evaluate the relationship between sensitization and asthma morbidity in urban adults.

METHODS

We prospectively studied 245 adults with persistent asthma recruited from an inner-city clinic. Sensitization to indoor allergens was evaluated by specific IgE antibodies measured at enrollment. Data on asthma control, asthma-related emergency department visits, hospitalizations, and oral steroid use were collected at baseline and at 1-month and 3-month follow-up contacts. Univariate, stratified, and multiple regression analyses were used to compare asthma morbidity in sensitized and nonsensitized patients after controlling for self-reported exposure and other potential confounders.

RESULTS

The study cohort consisted predominantly of low income, minority patients with high rates of resource utilization. The prevalences of sensitization to cockroach, dust mite, cat, mold, and mouse were 60%, 43%, 41%, 21%, and 14%. On univariate analyses, patients sensitized to each allergen did not have worse asthma control or higher resource utilization compared with nonsensitized individuals. Stratified and multivariate analyses also showed no association between sensitization and several measures of asthma morbidity even after controlling for self-reported exposure to indoor allergens and other potential confounders.

CONCLUSION

Sensitization to indoor allergens does not appear to be associated with increased asthma morbidity in inner-city adults.

CLINICAL IMPLICATIONS

These findings suggest that efforts to improve asthma control among urban populations should focus on other modifiable risk factors for morbidity.

Indoor ultrafine particle exposures and home heating systems: a cross-sectional survey of Canadian homes during the winter months

Exposure to airborne particulate matter has a negative effect on respiratory health in both children and adults. Ultrafine particle (UFP) exposures are of particular concern owing to their enhanced ability to cause oxidative stress and inflammation in the lungs. In this investigation, our objective was to examine the contribution of home heating systems (electric baseboard heaters, wood stoves, forced-air oil/natural gas furnace) to indoor UFP exposures. We conducted a cross-sectional survey in 36 homes in the cities of Montréal, Québec, and Pembroke, Ontario. Real-time measures of indoor UFP concentrations were collected in each home for approximately 14 h, and an outdoor UFP measurement was collected outside each home before indoor sampling. A home-characteristic questionnaire was also administered, and air exchange rates were estimated using carbon dioxide as a tracer gas. Average UFP exposures of 21,594 cm(-3) (95% confidence interval (CI): 14,014, 29,174) and 6660 cm(-3) (95% CI: 4339, 8982) were observed for the evening (1600-2400) and overnight (2400-0800) hours, respectively. In an unadjusted comparison, overnight baseline UFP exposures were significantly greater in homes with electric baseboard heaters as compared to homes using forced-air oil or natural gas furnaces, and homes using wood stoves had significantly greater overnight baseline UFP exposures than homes using forced-air natural gas furnaces. However, in multivariate models, electric oven use (beta=12,253 cm(-3), 95% CI: 3524, 20,982), indoor relative humidity (beta=1136 cm(-3) %, 95% CI: 372, 1899), and indoor smoking (beta=18,192 cm(-3), 95% CI: 2073, 34,311) were the only significant determinants of mean indoor UFP exposure, whereas air exchange rate (beta=4351 cm(-3) h(-1), 95% CI: 1507, 7195) and each 10,000 cm(-3) increase in outdoor UFPs (beta=811 cm(-3), 95% CI: 244,1377) were the only significant determinants of overnight baseline UFP exposures. In general, our findings suggest that home heating systems are not important determinants of indoor UFP exposures.

The Latino paradox in neighborhood context: the case of asthma and other respiratory conditions

OBJECTIVES

Evidence indicates that foreign-born Latinos have a health advantage compared with US-born persons of the same socioeconomic status. An explanation for this paradox has remained elusive. We examined the extent to which this paradox exists for the prevalence of asthma and other respiratory conditions. We then explored the role of neighborhood social context in understanding any observed advantage. We invoked theories of social organization, collective efficacy, and the urban ethnic enclave.

METHODS

We combined data from the Project on Human Development in Chicago Neighborhoods Community Survey with 2 other data sources and used hierarchical generalized linear modeling techniques.

RESULTS

We found a distinctly graded effect for asthma and other breathing problems among foreign-born Latinos, depending on community composition. Foreign-born Latinos embedded in a neighborhood that had a high percentage of foreign-born residents experienced a significantly lower prevalence of asthma and other breathing problems; those in communities that had a low percentage of foreign-born residents had the highest prevalence overall (even when compared with African Americans).

CONCLUSIONS

Foreign-born Latinos have a respiratory health advantage only in enclave-like settings. Contexts such as these may provide the cohesiveness critical for effective prevention.

The health of homeless children revisited

To the extent that representative data are available for specific health conditions (eg, under-immunization, asthma prevalence), the authors' data suggest that the gap between the health status of homeless children and housed children in minority, low-income families is narrowing. Studies of the health status of homeless children allow a window into the health status of medically underserved children whose needs may not be readily documented because of their lack of access to the health care system. Although prevalence rates of most of the health conditions discussed in this article exceeded national norms, they were generally consistent with rates characteristic of health disparities based on race-ethnicity and income. It must be emphasized that in most instances, children were seen for their first pediatric visit within weeks of entering the homeless shelter system. The health conditions identified were often present before the child and family became homeless. The high prevalence of asthma among homeless children should therefore be a matter of concern to health providers and payors, because the authors' data strongly suggest that this is not confined to children in homeless shelters as a special population. Similarly, childhood obesity predates homelessness (or at least the episode of homelessness during which health care was provided) and as such the authors' data may indicate the extent of this problem more generally among medically underserved children in the communities of origin. These conditions seem to be exacerbated by the specific conditions associated with homeless shelter life. Asthma care, assuming it was previously available, is disrupted when housing is lost, and shelter conditions may have multiple asthma triggers. Nutrition often suffers as a result of inadequate access to nutritious food and cooking facilities in shelters, as indicated by the high rate of iron-deficiency anemia among very young children. It is clear that homeless children in shelters require enhanced access to primary and specialist care. Shelter placement necessarily disrupts prior health care relationships (if any), while simultaneously placing additional stress on the child's physical and emotional well being. A medical home model is strongly recommended to allow for continuous, culturally competent care. Developmental and mental health problems are also more prevalent among homeless children. These conditions may jeopardize life successes. The overcrowding associated with homeless shelters and the housing conditions that frequently precede episodes of homelessness are associated with the higher prevalence of otitis media found among young children. This in turn is associated with developmental delay. Also contributing to the developmental risk associated with homelessness is exposure to DV, which is also frequently an antecedent of homelessness. Developmental surveillance for young, homeless children, monitoring of school attendance and academic performance, and assessment of mental status for homeless adolescents are recommended to facilitate early identification of problems and delivery of necessary interventions. For young children, providers of health care to the homeless should be well networked into the Early Intervention and Preschool Special Education programs in their locality. Given the multiplicity of needs for homeless families, which of course includes help finding affordable housing, health care providers serving this population should also develop linkages with community agencies, including those that can help parents develop the skills necessary for economic self-sufficiency and long-term ability to sustain independent housing.

Childhood asthma prevalence in northern Puerto Rico, the Rio Grande, and Loíza experience

OBJECTIVE

Childhood asthma is highly prevalent in some areas of Puerto Rico. The objective of this study was to estimate the prevalence of asthma in two municipalities of Northern Puerto Rico.

METHODS

Children 6 to 7 and 13 to 14 years of age participated in the school-based cross-sectional study.

RESULTS

A total of 1,467 elementary school students and 1,334 junior-high school students were included in the survey. A high prevalence of asthma was observed; 46% in elementary schools and 24% in junior-high schools. In elementary schools, family history of asthma (FHA) was associated with ever wheezed (PR = 2.00, 95%CI 1.59, 2.52), wheeze during last year (PR = 2.02, 95%CI 1.54, 2.62), and asthma (PR = 2.33, 95%CI 1.86, 2.92). For junior-high schools FHA was associated with ever wheezed (PR = 2.01, 95%CI 1.56, 2.57), wheeze during previous year (PR = 2.00, 95%CI 1.47, 2.73), and asthma (PR = 2.72, 95%CI 2.06, 3.60).

CONCLUSIONS

This study showed a high prevalence of asthma and related symptoms in Northern Puerto Rico. FHA was strongly associated with asthma and its symptoms. Further research is recommended to look at genetics, sensitivity levels, indoor and outdoor pollution, and gene-environment interactions.

Co-occurrence of mental and physical illness in US Latinos

BACKGROUND

This study describes the prevalence of comorbid physical and mental health problems in a national sample of US Latinos. We examined the co-occurrence of anxiety and depression with prevalent physical chronic illnesses in a representative sample of Latinos with national origins from Mexico, Cuba, Puerto Rico, and other Latin American countries.

METHOD

We used data on 2,554 Latinos (75.5% response rate) ages 18 years and older from the National Latino and Asian American Study (NLAAS). The NLAAS was based on a stratified area probability sample design, and the sample came from the 50 states and Washington, DC. Survey questionnaires were delivered both in person and over the telephone in English and Spanish. Psychiatric disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI). Physical chronic illness was assessed by self-reported history.

RESULTS

Puerto Ricans had the highest prevalence of meeting criteria for any comorbid psychiatric disorder (more than one disorder). Puerto Ricans had the highest prevalence (22%) of subject-reported asthma history, while Cubans had the highest prevalence (33%) of cardiovascular disease. After accounting for age, sex, household income, number of years in the US, immigrant status, and anxiety or depression, anxiety was associated with diabetes and cardiovascular disease, in the entire sample. Depression and co-occurring anxiety and depression were positively associated with having a history of asthma but not with other physical diseases, in the entire sample. Interestingly, Puerto Ricans with a depressive disorder had a lower odds of having a history of cardiovascular disease than Puerto Ricans without a depressive disorder. The relationship between chronic physical and mental illness was not confounded by immigration status or number of years in the US.

DISCUSSION

Despite previous findings that link acculturation with both chronic physical and mental illness, this study does not find that number of years in the US nor nativity explain the prevalence of psychiatric-medical comorbidities. This study demonstrates the importance of considering psychiatric and medical comorbidity among specific ethnic groups, as different patterns emerge than when using aggregate ethnic measures. Research is needed on both the pathways and the mechanisms of comorbidity for the specific Latino groups.

Asthma in Hispanics in the United States

The Hispanic population in the United States is diverse in many respects. Although there is marked variation in the prevalence, morbidity, and mortality of asthma among Hispanic subgroups in the United States, these differences are poorly understood. Future stu-dies of asthma should include large samples of Hispanic subgroups that are well characterized in terms of self-reported ethnicity, country of origin, place of birth, area of residence, and indicators of socioeconomic status. Because a significant proportion of Hispanics live in poverty, public health interventions aimed at improving access to health care and housing conditions would have a major impact on reducing asthma morbidity among Hispanics in the United States.

Disparities in the use of urgent health care services among asthmatic children

BACKGROUND

Urgent care composes one third of the total costs associated with asthma. Asthmatic children of African American and Latino backgrounds have higher rates of emergency department (ED) use and hospitalizations than white children, especially in urban settings.

OBJECTIVE

To evaluate the role of socioeconomic, disease-related, and access-to-care factors in utilization of the ED and inpatient services for urgent treatment of asthma.

METHODS

A parent-response questionnaire was systematically distributed in public elementary schools that serve children of different socioeconomic backgrounds in New York City.

RESULTS

The prevalence of current asthma was found to be 13.0% in 5- to 12-year-old children. Almost half of the current asthmatic patients had used urgent care in the ED or hospital in the previous 12 months. In univariate analysis, use of urgent care was strongly associated with race/ethnicity and income (P < .001). Adjusting for socioeconomic, disease-related, and access-to-care factors, including household income, symptom severity, type of health insurance, and usual source of asthma care, the racial/ethnic disparity persisted, with Latinos having 5 times the risk and African Americans having double the risk of using urgent care as whites.

CONCLUSIONS

There is a failure in asthma management in this urban population, demonstrated by the finding that almost half of all current asthmatic patients used urgent care. After controlling for different socioeconomic and disease-related factors, minority race/ethnicity, low household income, and frequent evening symptoms were found to be strong predictors of urgent care utilization. Insurance status, delaying care for any reason, and use of controller medications were found not to be associated with urgent care use.

Asthma disparities in the prevalence, morbidity, and treatment of Latino children

The paper reviews the existing research related to asthma disparities and frames the results of this research within a conceptual model modified from the Institute of Medicine model in order to explain asthma health disparities in Latino children in the USA. The model of pediatric asthma disparity presented is based on the conceptualization of health disparities as the result of a complex interaction of factors related to four main domains: the individual and family, the environment or context in which the child lives, the health-care system, and provider characteristics. Asthma disparities are discussed as they are reflected in the process of care (access and quality of treatment) and outcome (prevalence, morbidity, severity) experienced by Latino children. The potential mechanisms that may account for the asthma disparities documented as reflected by the conceptual model proposed are discussed. Finally, several suggestions for future research examining determinants that account for asthma disparities are examined.

Asthma and enrollment in special education among urban schoolchildren

OBJECTIVES

We assessed whether asthma is associated with urban children's use of special education services.

METHODS

We conducted a cross-sectional study in 24 randomly selected New York City public elementary schools using a parent-report questionnaire focusing on sociodemographic characteristics, special education enrollment, asthma diagnosis and symptoms, school absences, and use of health care services.

RESULTS

Thirty-four percent of children enrolled in special education had been diagnosed with asthma, compared with 19% of children in the general student population. After control for sociodemographic factors, children with asthma were 60% more likely than children without asthma to be enrolled in special education (odds ratio [OR] = 1.62; 95% confidence interval [CI] = 1.22, 2.16). Asthmatic children in special education were significantly more likely to be from low-income families and to have been hospitalized in the previous 12 months than asthmatic children in general education.

CONCLUSIONS

Inadequate asthma control may contribute to a greater risk of asthmatic children residing in urban areas being placed in special education. School health programs should consider targeting low-income urban children with asthma at risk for enrollment in special education through increased asthma interventions and medical support services.