Asthma prevalence and risk factors in selected Head Start sites in Chicago

Childhood asthma and mould in homes-A meta-analysis

Asthma is a multifaceted and multicausal disease. Childhood asthma is strongly influenced by genetic traits and is characterized by hyperreactivity of the airways so that also unspecific triggers including moulds can trigger an asthma attack. Therefore, it is undisputed that moulds in the home can cause asthma attacks in asthmatic children. It is, however, unclear if mould in homes also induce the development of asthma. Because more and more severe attacks in asthmatic children living in mouldy homes might speed up the diagnosis of asthma, cross-sectional studies are not well-suited to differentiate between mould as a causative or only as a precipitating factor. Cross-sectional studies show an increased asthma risk and poorer lung function in children living in mouldy homes. To better understand the causal role of mould in homes, a systematic review was performed with random effects meta-analysis focusing on cohort and case-control studies only.We found 21 case-control and 11 cohort studies examining the association between mould at home and later advent of childhood asthma. According to the case-control studies, mouldy homes increase the risk of asthma by 53% (95 confidence interval [CI]: 42-65%) with no evidence of heterogeneity or publication bias. Risk estimates based on cohort studies were smaller with 15% (1-31%). The cohort studies also showed no publication bias but substantial heterogeneity (I2 = 60.5, p = 0.005). Heterogeneity could be partly explained by percentage of male children, age of participants, and publication year, but was not affected by study quality.In conclusion, living in mouldy homes during childhood seems to increase the risk of later developing bronchial asthma.

Association between exposure to the Chinese famine during infancy and the risk of self-reported chronic lung diseases in adulthood: a cross-sectional study

OBJECTIVE

To examine the association between early-life exposure to the Chinese famine and the risk of chronic lung diseases in adulthood.

DESIGN

Data analysis from a cross-sectional survey.

SETTING AND PARTICIPANTS

4135 subjects were enrolled into the study from the China Health and Retirement Longitudinal Study (CHARLS) 2011-2012 baseline survey to analyse the associations between prenatal and early postnatal famine exposure and the risk of chronic lung diseases in adulthood.

MAIN OUTCOME MEASURES

Chronic lung diseases were defined based on self-reported information.

RESULTS

The prevalence of self-reported chronic lung diseases in fetus-exposed, infant-exposed, preschool-exposed, and non-exposed groups was 6.5%, 7.9%, 6.8%, and 6.1%, respectively. The risk of chronic lung diseases in the infant-exposed group was significantly higher (OR 1.95, 95% CI 1.10 to 3.44) than the non-exposed group in severely affected areas, even after adjusting for gender, smoking, and drinking, family economic status, and the highest educational attainment of the parents (OR 2.57, 95% CI 1.26 to 5.25). In addition, after stratification by gender and famine severity, we found that only infant exposure to the severe famine was associated with the elevated risk of chronic lung diseases among male adults (OR 3.16, 95% CI 1.17 to 8.51).

CONCLUSIONS

Severe famine exposure during the period of infancy might increase the risk of chronic lung diseases in male adults.

Home dust microbiota is disordered in homes of low-income asthmatic children

OBJECTIVE

Exposure to microorganisms has repeatedly been found to influence development of atopic diseases, such as asthma. Innovative techniques have been developed that can comprehensively characterize microbial communities. The objective of this study was to characterize the home microbiota of asthmatic children utilizing 16S rRNA-based phylogenetic analysis by microarray.

METHODS

In this cross-sectional study, DNA was extracted from home dust and bacterial 16S rRNA genes amplified. Bacterial products were hybridized to the PhyloChip Array and scanned using a GeneArray scanner (Affymetrix, Santa Clara, CA). The Adonis test was used to determine significant differences in the whole microbiome. Welch's t-test was used to determine significant abundance differences and genus-level richness differences.

RESULTS

Nineteen homes were included in the analysis (14 asthma and five no asthma). About 1741 operational taxonomic units (OTUs) were found in at least one sample. Bacterial genus richness did not differ in the homes of asthmatics and non-asthmatics (p = 0.09). The microbial profile was significantly different between the two groups (p = 0.025). All the top 12 OTUs with significant abundance differences were increased in homes of asthmatics and belonged to one of the five phyla (p = 0.001 to p = 7.2 × 10(-6)). Nearly half of significant abundance differences belonged to the phylum Cyanobacteria or Proteobacteria.

CONCLUSIONS

These results suggest that home dust has a characteristic microbiota which is disturbed in the homes of asthmatics, resulting in a particular abundance of Cyanobacteria and Proteobacteria. Further investigations are needed which utilize high-throughput technology to further clarify how home microbial exposures influence human health and disease.

Birth weight and childhood wheezing disorders: a systematic review and meta-analysis

BACKGROUND

Previous observational studies have claimed that birth weight and childhood wheezing disorders are associated although the results remained inconsistent. One systematic review and two systematic reviews that included meta-analyses reported inconsistent results. We aimed to conduct a systematic review and meta-analysis to investigate this.

METHODS

An online search of published papers linking childhood asthma and wheezing disorders with birth weight up to February 2014 was carried out using EMBASE and Medline medical research databases. Summary ORs were estimated using random-effects models. Subgroup meta-analyses were performed to assess the robustness of risk associations and between-study heterogeneity.

RESULTS

A total of 37 studies comprising 1,71, 737 participants were included in our meta-analysis. The unadjusted summary ORs for risk of childhood wheezing disorders associated with low birth weight (<2.5 kg) were 1.60 (95% CI 1.39 to 1.85, p<0.001) and 1.37 (95% CI 1.05 to 1.79, p=0.02) when compared with ≥2.5 and 2.5-4.0 kg birthweight groups, respectively. The overall summary OR for high birth weight (>4 kg) as compared to the 2.5-4.0 kg birthweight group was 1.02 (95% CI 0.99 to 1.04, p=0.13). There was substantial heterogeneity in the unadjusted low birth weight risk estimates which was not accounted for by predefined study characteristics. There was no significant heterogeneity in the high birth weight risk estimates. There was some evidence of funnel plot asymmetry and small study effects in the low birth weight (2.5 vs ≥2.5 kg and <2.5 vs 2.5-4 kg) OR estimates.

CONCLUSIONS

Our results suggest that low birth (<2.5 kg) is an independent risk factor for wheezing disorders during childhood and adolescence although there was substantial heterogeneity among the risk estimates. However, we found no significant association of high birth weight with wheezing disorders.

A community-based strategy for improving asthma management and outcomes for preschoolers

Although almost one in ten (8.6%) preschool children has been diagnosed with asthma, few asthma management programs are designed for parents of preschool children. The Asthma Basics for Children program addressed this need in 2003-2008 by implementing a multi-layered approach that offered educational activities to center staff, parents, and children and PACE training to physicians in 31 Northern Manhattan daycare centers. Following program participation, 85% of parents reported reducing their child's triggers, 89% said it was easier to talk to their child's physician, and 80% were confident in their ability to manage their child's asthma. Children's any daytime symptoms dropped from 78% to 42%, any nighttime symptoms from 81% to 49%, any daycare absences from 56% to 38%, any asthma-related emergency department (ED) visits from 74% to 47%, and any asthma-related hospitalizations from 24% to 11% (p < .001 for all differences). Outcomes varied by level of exposure. In the Center-Only group (no parent participation), the only reduction was from 19% to 10% (McNemar = 3.77, p = .052) in hospitalizations. Children whose parents participated in the program had significant reductions in daycare absences (62% to 38%, McNemar = 11.1, p < .001), ED visits (72% to 43%, McNemar = 19.2, p < .001), and hospitalizations (24% to 11%, McNemar = 5.54, p = .018). Children whose parents and healthcare provider participated had the greatest improvements with asthma-related daycare absences dropping from 62% to 32% (McNemar = 9.8, p = .001), ED visits from 72% to 37% (McNemar = 14.4, p < .001), and hospitalizations from 35% to 15% (McNemar = 8.33, p = .003). This study demonstrates that a multi-layered approach can improve asthma outcomes among preschoolers with a combination of parent and provider education having the greatest impact.

Addressing asthma management challenges in a multisite, urban Head Start program

OBJECTIVE

To develop an action plan based on asthma management challenges identified by Head Start teachers in a multisite program.

DESIGN AND SAMPLE

Qualitative, participatory action research project. Three focus groups were conducted with Head Start teachers (n=14), and 1 with Center managers (n=15) in an urban Midwestern program.

MEASURES

Brief background questionnaire and semistructured focus group interview guide. Content analytic techniques were used to identify and categorize asthma management issues in transcripts of teacher focus groups. Center managers verified the findings and recommended action plan strategies to address asthma management challenges.

RESULTS

Head Start staff identified 4 common challenges: (a) undiagnosed and unreported asthma, (b) coordinating asthma care with parents, (c) medication administration issues, and (d) variability among asthma action plans. The action plan focused on (a) early identification of asthma, (b) improving coordination of asthma care with parents, (c) developing more asthma education and resources for Head Start staff and parents, and (d) developing a standardized, comprehensive Head Start asthma action plan.

CONCLUSIONS

Public health nurses can play a major role in ensuring quality care in Head Start programs by periodically identifying staff needs and developing strategies to address asthma management challenges.

The continuing problem of asthma in very young children: a community-based participatory research project

BACKGROUND

Asthma is a chronic health condition that has a disproportionate effect on low-income minority children who reside in large urban areas. African-American children report significantly higher rates than the general population of children and have more-severe asthma and poorer outcomes. This article describes the prevalence of asthma in a particularly vulnerable group: children aged 2-5 participating in Detroit Head Start programs.

METHODS

Health screens were distributed to caretakers of all children attending 6 Head Start agencies. Caretakers of children identified with active asthma symptoms were asked to complete an in-depth phone interview regarding their child's asthma.

RESULTS

Data collected from 3,254 children (78% African American) revealed that 27% met criteria for probable asthma. Of those with persistent symptoms, 26% were undiagnosed, and 21% were untreated. Baseline data (n = 675) showed that 95% had a regular doctor, but 36% had had no health care visit for asthma in the previous year. Of children with a history of asthma episodes, more than half reported 3 or more episodes in the preceding year. Forty-three percent of caretakers had discussed their child's asthma with Head Start, and 31% had an asthma action plan on file with Head Start.

CONCLUSIONS

Asthma remains a significant problem in this population, especially for African Americans, as evidenced by high levels of undiagnosed children with persistent symptoms and questions regarding the care they receive. Head Start is a way to reach young children with asthma, but may need help to develop the capacity to assist families.

Parent-reported medication use in a head start population

This study investigates the prevalence of medication use within a Head Start population. Parent-reported data (N = 1,397) from initial enrollment information indicated 6.8% of children were taking 34 different types of medication. More than two thirds (69%) of those on medication were prescribed more than one medication, and more than one third (37%) were taking three or more medications. The majority of children were reported to be taking medications that were asthma (88%) or allergy (17%) related. Psychotropic medications accounted for 4% of the medications, indicating a prevalence of less than 0.3%. African American and Hispanic children were overrepresented in those taking medicines. School nurses can work with parents and caregivers of Head Start children by raising awareness of (1) the benefits and side effects of medications commonly taken within this population, (2) the significant role that asthma medications play in low-income areas, and (3) the issues and challenges associated with polypharmacy practices.

Asthma management simulation for children: translating theory, methods, and strategies to effect behavior change

Translating behavioral theories, models, and strategies to guide the development and structure of computer-based health applications is well recognized, although a continued challenge for program developers. A stepped approach to translate behavioral theory in the design of simulations to teach chronic disease management to children is described. This includes the translation steps to: 1) define target behaviors and their determinants, 2) identify theoretical methods to optimize behavioral change, and 3) choose educational strategies to effectively apply these methods and combine these into a cohesive computer-based simulation for health education. Asthma is used to exemplify a chronic health management problem and a computer-based asthma management simulation (Watch, Discover, Think and Act) that has been evaluated and shown to effect asthma self-management in children is used to exemplify the application of theory to practice. Impact and outcome evaluation studies have indicated the effectiveness of these steps in providing increased rigor and accountability, suggesting their utility for educators and developers seeking to apply simulations to enhance self-management behaviors in patients.

Asthma burden in a citywide, diverse sample of elementary schoolchildren in Chicago

OBJECTIVE

The purposes of this study are to describe and develop preliminary models of the burden of diagnosed asthma and symptoms of possible undiagnosed asthma in a large, citywide, ethnically and socioeconomically diverse sample of Chicago elementary schoolchildren. We hypothesized that considering possible asthma would give a more complete picture of race/ethnic disparities in pediatric asthma.

METHODS

We studied 35,583 students aged 6 to 12 years attending Chicago Public and Archdiocese elementary schools for the Chicago Initiative to Raise Asthma Health Equity (CHIRAH) study. The full enrollments of 105 schools were surveyed for asthma and possible undiagnosed asthma by the Brief Pediatric Asthma Screen Plus (BPAS+) respiratory symptoms. The child had to be 6 to 12 years old, the valid age range for the BPAS+. Questionnaires included the BPAS+, basic demographic information, and household asthma information; they were sent home with each schoolchild for completion by the parent and returned to school for collection and scoring.

RESULTS

Overall, 13.9% of students had diagnosed asthma. For children aged 6 to 12 years, rates of diagnosed asthma varied from 13.1% to 14.5%, whereas the rates of possible undiagnosed asthma varied from 14.8% to 10.9%. The rate of diagnosed asthma was 21.2% for African Americans, 9.7% for whites, 11.8% for Hispanics, with similar rates of possible undiagnosed asthma. By multinomial logistic regression, African Americans were more than twice as likely and Hispanics were 1.57 times more likely than whites to have diagnosed asthma at all school district income levels and controlling for other household members with asthma, type of school, age of the child, gender, and language preference. The odds of African Americans being diagnosed with asthma rather than having possible asthma were 76% higher and for Hispanics were 46% higher compared with whites, at all school district income levels and controlling for other household members with asthma, type of school, age of the child, gender, and language preference.

CONCLUSIONS

Our study confirms national disparities in diagnosed asthma by race/ethnicity. Respiratory symptoms consistent with possible undiagnosed asthma increase the total potential burden of asthma overall to more than one-quarter of the school enrollees. Among students with respiratory symptoms, African Americans, Hispanics (controlling for language), and families where another person has asthma are more likely to have diagnosed rather than possible asthma. Improved knowledge about asthma, recognition of symptoms, and access to high-quality care are necessary to ascertain how much of the possible undiagnosed asthma represents additional cases of asthma requiring treatment.

Are we closing the disparities gap? Small-area analysis of asthma in Chicago

Disparities in asthma outcomes in the Chicago area have been observed between geographic areas and ethnic and socioeconomic groups. As efforts to close this gap have moved beyond the initial characterization of the problem to implementation of concrete programs to address these disparities, objective measures of success are essential. We present a variety of data from the Chicago area to assess whether any improvement in previously reported disparities can be demonstrated. While some process outcomes such as medication usage have improved over time, death from asthma has failed to demonstrate an equivalent improvement. More importantly, the differential in asthma mortality and hospitalization rates between African Americans and European Americans has failed to close in the years following the release of the National Asthma Education and Prevention Program asthma guidelines.

Pulmonary testing using peak flow meters of very low birth weight children born in the perisurfactant era and school controls at age 10 years

We determined lung function at age 10 years in very low birthweight (VLBW, <or=1,500 g) children and controls, and compared the sensitivity to detect subgroup differences by peak expiratory flow (PEF), forced expiratory volume in one second (FEV(1)), forced vital capacity (FVC) and their diurnal variation. VLBW children were recruited across the perisurfactant era at admission to six NICUs in Wisconsin and Iowa, and controls from area classrooms. Two hundred sixty five VLBW children and 360 controls were tested by the Jaeger AM1 peak flow meter at age 10 years. Two hundred six VLBW and 79 controls had additional home monitoring. Abnormality was defined as observed/predicted ratio <0.8 for PEF, FEV(1), and FVC, and by criteria of Pelkonen for diurnal PEF variation. VLBW children were compared to controls, VLBW children with bronchopulmonary dysplasia (BPD) to those without, and those with respiratory conditions to those without. PEF and FEV(1) showed high reproducibility (intraclass correlations, ICC 0.75-0.83). Controls and VLBW children with and without BPD differed significantly on all measures. Baseline test results did not differ across birth years, but PEF variation was less after surfactant availability (P = 0.04). Observed over predicted FEV(1) was the most sensitive in detecting differences between groups (P < 0.001), with mean (s.d.) 0.97 (0.12) for controls, 0.88 (0.14) for VLBW children without BPD, and 0.78 (0.13) for those with BPD. Odds ratios for abnormality were especially high with respiratory medication use during the first 5 years of life, 4.4 (95% CI: 2.0-9.8) for FEV(1) and 5.1 (95% CI: 2.0-13.2) for diurnal PEF variation. Our results show that respiratory abnormalities persist to at least age 10 years for VLBW children born in the surfactant era.

Meta-analyses of the associations of respiratory health effects with dampness and mold in homes

The Institute of Medicine (IOM) of the National Academy of Sciences recently completed a critical review of the scientific literature pertaining to the association of indoor dampness and mold contamination with adverse health effects. In this paper, we report the results of quantitative meta-analyses of the studies reviewed in the IOM report plus other related studies. We developed point estimates and confidence intervals (CIs) of odds ratios (ORs) that summarize the association of several respiratory and asthma-related health outcomes with the presence of dampness and mold in homes. The ORs and CIs from the original studies were transformed to the log scale and random effect models were applied to the log ORs and their variance. Models accounted for the correlation between multiple results within the studies analyzed. Central estimates of ORs for the health outcomes ranged from 1.34 to 1.75. CIs (95%) excluded unity in nine of 10 instances, and in most cases the lower bound of the CI exceeded 1.2. Based on the results of the meta-analyses, building dampness and mold are associated with approximately 30-50% increases in a variety of respiratory and asthma-related health outcomes.

PRACTICAL IMPLICATIONS

The results of these meta-analyses reinforce the IOM's recommendation that actions be taken to prevent and reduce building dampness problems, and also allow estimation of the magnitude of adverse public health impacts associated with failure to do so.

Public health and economic impact of dampness and mold

The public health risk and economic impact of dampness and mold exposures was assessed using current asthma as a health endpoint. Individual risk of current asthma from exposure to dampness and mold in homes from W.J. Fisk, Q. Lei-Gomez & M.J. Mendell [(2007) Indoor Air, [corrected] 17, 284-296], and [corrected] asthma risks calculated from additional studies that reported the prevalence of dampness and mold in homes were used to estimate the proportion of US current asthma cases that are attributable to dampness and mold exposure at 21% (95% confidence internal 12-29%). An examination of the literature covering dampness and mold in schools, offices, and institutional buildings, which is summarized in the Appendix, suggests that risks from exposure in these buildings are similar to risks from exposures in homes. Of the 21.8 million people reported to have asthma in the USA, approximately 4.6 (2.7-6.3) million cases are estimated to be attributable to dampness and mold exposure in the home. Estimates of the national cost of asthma from two prior studies were updated to 2004 and used to estimate the economic impact of dampness and mold exposures. By applying the attributable fraction to the updated national annual cost of asthma, the national annual cost of asthma that is attributable to dampness and mold exposure in the home is estimated to be $3.5 billion ($2.1-4.8 billion). Analysis indicates that exposure to dampness and mold in buildings poses significant public health and economic risks in the USA. These findings are compatible with public policies and programs that help control moisture and mold in buildings.

PRACTICAL IMPLICATIONS

There is a need to control moisture in both new and existing construction because of the significant health consequences that can result from dampness and mold. This paper demonstrates that dampness and mold in buildings is a significant public health problem with substantial economic impact.

Computer-based decision support for pediatric asthma management: description and feasibility of the Stop Asthma Clinical System

Clinical guidelines can assist in the management of asthma. Decision support systems (DSSs) can enhance adherence to clinical guidelines but tend not to provide clinicians with cues for behavioral change strategies to promote patient self-management. The Stop Asthma Clinical System (SACS) is a DSS designed for this purpose. To assess feasibility, seven clinicians used SACS to guide well visits with 26 predominantly persistent pediatric asthma patients. Data were collected via survey and in-depth semi-structured interviews. SACS improved assessment of asthma severity and control, classification of and intervention in medicine and environmental trigger management problems, and development of an action plan (all p < 0.05). Clinician-patient communication was enhanced. The primary challenge was that SACS increased clinic visit time. SACS can enhance clinician behavior to improve patient asthma self-management, but more studies are indicated to mitigate temporal constraints and evaluate impact on clinician and patient communication and behavior as well as clinical outcomes.

Validating an asthma case detection instrument in a Head Start sample

Although specific tests screen children in preschool programs for vision, hearing, and dental conditions, there are no published validated instruments to detect preschool-age children with asthma, one of the most common pediatric chronic conditions affecting children in economically disadvantaged communities of color. As part of an asthma education intervention, a 15-item Brief Respiratory Questionnaire (BRQ) was developed to detect children with probable asthma in Head Start and subsidized preschool settings in communities with high asthma prevalence and associated morbidity. Preschool personnel administered the BRQ to consenting parents of 419 enrolled children. Trained interviewers administered validation interviews (VALs) to parents of 149 case-positive children and 51 case-negative children. Three physicians independently assessed deidentified summaries of the VALs that captured responses about signs and symptoms of asthma, diagnosis and treatment, and use of medical services. The physicians' assessments of the summarized VALs were the validated standard to which the BRQ classifications were compared. A simple algorithm of 4 items was identified that can be administered and scored by nonmedical preschool personnel in less than 5 minutes. The chance-corrected agreement between these 4 items of the BRQ and the VAL was good: kappa, .73 (95% confidence interval, 0.62-0.84); specificity, 96%; sensitivity, 73%; and positive predictive value, 97%. The BRQ appears to be a valid instrument for detecting children with probable asthma in Head Start and other subsidized preschool settings in communities with high prevalence of asthma.

Environmental allergens and asthma morbidity in low-income children

Asthma morbidity is high in inner-city children in the United States, which may be related in part to increased allergens in poorly maintained housing. This study examined asthma morbidity in relation to mold, cockroach, dust mite, and cat allergens in the homes of 61 low-income Chicago children with asthma. Children exposed to higher levels of Penicillium in the bedroom had more frequent asthma symptoms, whereas those exposed to higher levels of cockroach allergen in the bedroom had a higher number of asthma symptoms. Respiratory infections confounded the association of cockroach allergen with number of asthma symptoms.

Working with a Head Start population with asthma: lessons learned

The Early Childhood Asthma Project involved asthma case identification in 35 Head Start centers in Detroit, MI, and attempted implementation of an intervention designed to help families manage a child's asthma more effectively. Surveys were distributed to the parents of all Head Start children (3408), and 2198 complete surveys were returned. Case detection found probable asthma in 30% of the children whose parent returned a sufficiently complete survey. Implementation of the intervention was unsuccessful in this setting. Obstacles to effective implementation included the sample's low participation and high attrition, limited involvement of Head Start personnel, factors related to the program approach, and the target population's beliefs about asthma.

Self-reported moisture or mildew in the homes of Head Start children with asthma is associated with greater asthma morbidity

This study used results from a cross-sectional survey of parents of 3- to 5-year-old children with asthma to assess the frequency of self-reported home environmental conditions that could contribute to worsening asthma and examined the relationship between these factors and the child's asthma morbidity. Participants were 149 parents drawn from the two largest agencies that provide subsidized preschool childcare services in East and Central Harlem, inner-city communities with high prevalence of asthma. The sample represented 77% of eligibles determined by a validated case-identification instrument. Data were collected on demographics, symptoms, medication use, Emergency Department visits and hospitalization, and environmental conditions in the home. One or more of these home environmental conditions were reported by 92% of participants. Controlling for other environmental conditions and demographics, associations were found between self-reported presence of moisture or mildew on ceilings, walls, or windows and higher frequency of hospitalizations for breathing-related problems (OR = 3.31; 95% CI 1.62-6.75), frequent episodes of wheezing (OR = 3.25; 95% CI 1.8-6.0), and higher frequency of night symptoms due to asthma (OR = 2.19; 95% CI 1.4-3.41). Having a carpet or rug in the child's bedroom or the living room was also associated with hospitalizations (OR = 3.23; 95% CI 1.53-6.8), and male gender was marginally associated with the frequency of night symptoms (OR = 1.51; 95% CI .95-2.4). Asthma is prevalent in the Head Start population, and exposure to home environmental conditions that may worsen asthma is common in the socially disadvantaged populations served by Head Start programs.

Identification of preschool children with asthma from low-income families in Los Angeles, CA

BACKGROUND

Few studies have addressed asthma screening in the preschool age group. Early asthma recognition and intervention in preschool children may reduce costs related to unscheduled medical care and missed school and work.

OBJECTIVE

To facilitate an early recognition and referral process for asthma in a preschool education program in Los Angeles, CA.

METHODS

We administered a 7-question survey to parents and guardians of children aged 12 months to 6 years in the prekindergarten program of a large school district in Southern California. English and Spanish survey questions addressed health care use, school absenteeism, and asthma symptoms. Postsurvey reports to parents recommended clinical evaluation of children who had probable asthma.

RESULTS

Of the 609 surveys returned from 8 centers (> or = 80% survey return rate), 12% were positive for probable asthma and only 5.4% of these cases had been previously diagnosed. Of the 12% found to have a high probability of asthma, 3 independent factors were associated with a lower likelihood of prior asthma diagnosis: Hispanic descent; Spanish speaking; and medicine use 2 or more times per week for symptoms such as cough, chest tightness, trouble breathing, or wheezing. Symptoms at play, during the day, and at night were noted in 35% to 44% of the preschoolers. Cough was the most frequently reported symptom (71.9%, n = 424).

CONCLUSIONS

A school-based screening process in an early education program can help identify preschool children with a high probability of asthma and offer a basis for early recognition and intervention.

Development of an expert system knowledge base: a novel approach to promote guideline congruent asthma care

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Asthma management practices and education needs of head start directors and staff

Limited information exists regarding asthma management practices and education needs of Head Start directors and staff. This paper describes asthma management practices and education needs of Head Start directors and staff in 15 Baltimore, Md., Head Start programs. From February to December 2000, all Head Start staff and directors were asked to complete a survey. Data from 268 Head Start staff and 12 Head Start directors were analyzed. Results revealed discrepancies between Head Start staff and directors regarding location of asthma medications and presence of asthma action plans in programs. Both Head Start staff and directors stated they had no curriculum to teach Head Start children how to manage asthma. This finding provides evidence that asthma education is needed in Head Start programs. Findings also indicate a need for improved communication between Head Start directors and staff.

Issues in identifying asthma and estimating prevalence in an urban school population

This article first presents salient issues related to identifying children in urban schools who might benefit from asthma services. It discusses a brief questionnaire for identifying cases and problems in estimating asthma prevalence. Subsequently, results of case detection in 14 urban schools are presented and discussed in light of these issues. The questionnaire was employed with parents of 4,653 African-American children in Detroit. Results suggest that determining number, type, and frequency of symptoms may be necessary to ascertain prevalence of asthma. Using only number and type produced a rate of asthma of 25%. Adding frequency provided a more conservative estimate of 19%. About 9% of children exhibiting symptoms of asthma had no physician diagnosis. Only 25% with symptoms reflecting mild persistent, 35% with moderate persistent, and 26% with severe persistent disease had prescriptions for anti-inflammatory medicine. Further, 23% of children with asthma-like symptoms had no prescription for asthma medicine of any type.

CONCLUSIONS

(1) low-cost procedures can be used in schools to identify children with suspected undiagnosed and undertreated asthma; (2) prevalence estimates for asthma in the group of urban school children studied are among the highest in the United States; and (3) asthma is undertreated in this sample.

A longitudinal study of the prevalence of asthma in a community population of school-age children

OBJECTIVE

Using a unique county-wide resource that links all health care providers' medical records to assess current and "ever" prevalence of physician-diagnosed asthma. To describe the age and sex rates and temporal trends in new asthma diagnoses and associations with race and socio-economic status.

STUDY DESIGN

A longitudinal retrospective evaluation of a population-based cohort of school children using linked medical and school records.

RESULTS

Overall, 17.6% of children in grades kindergarten through 12 had a physician diagnosis of asthma and 12.9% had an asthma-related visit within the past 2 years. An additional 19.7% had visits for reactive airway disease or recurrent wheezing or bronchospasm with no diagnosis of asthma. Children provided with free and reduced-cost lunches had lower cumulative and incident asthma rates from birth through their current school age. Race was not related to rates of physician-diagnosed asthma. There was a significant temporal increase in rates of new asthma diagnoses.

CONCLUSIONS

In this community, 1 in 3 children have had a physician-documented recurrent wheezing-type illness, and 1 in 6 were diagnosed with asthma. Diagnoses rates were directly related to socioeconomic status.

Atopy, lung function, and obstructive airways disease after prenatal exposure to famine

BACKGROUND

Associations have been found between a large head size at birth and atopy, and between low birth weight and obstructive airways disease. A study was undertaken of people born around the time of the Dutch famine in 1944-5 to determine the effects of maternal malnutrition during specific periods of gestation on the prevalence of obstructive airways disease and atopy.

METHODS

Nine hundred and twelve people aged about 50, born at term between November 1943 and February 1947 in Amsterdam, were asked about their medical history. Lung function was measured in 733 and serum concentrations of total IgE and specific IgE against mite, pollen and cat were measured in 726. Those exposed in late, mid, and early gestation (exposed participants) were compared with those born before or conceived after the famine (non-exposed participants).

RESULTS

Exposure to famine during gestation affected neither the concentrations of total or specific IgE nor lung function values. The prevalence of obstructive airways disease was increased in people exposed to famine in mid gestation (odds ratio adjusted for sex 1.7, 95% confidence interval (CI) 1.1 to 2.6) and tended to be higher in those exposed in early gestation (odds ratio 1.5, 95% CI 0. 9 to 2.6).

CONCLUSIONS

The observed increase in the prevalence of obstructive airways disease in people exposed to famine in mid and early gestation was not parallelled by effects on IgE concentrations or lung function. The link between exposure to famine in mid and early gestation and obstructive airways disease in adulthood suggests that fetal lungs can be permanently affected by nutritional challenges during periods of rapid growth.

Asthma in the inner city: a growing public health problem

Asthma in the inner city impacts people of all ages and is most pronounced in African Americans and other minorities. During the past decade, the prevalence of asthma has increased by 42%, a rate consistently higher in African Americans. Along with the increase in asthma prevalence, the costs associated with this disease have also risen dramatically. In addition, asthma is the leading cause of school absenteeism and also contributes to lost productivity. This article focuses on the epidemiology of asthma in urban areas and identifies various risk factors that are important in achieving control of this disease. Suggestions for future interventions are discussed.

Chicago community-based asthma intervention trial: feasibility of delivering peer education in an inner-city population

The most effective means of educating children with asthma and their families has not been clearly demonstrated in previous studies. Peer education is uniquely suited to the complex problems encountered in underserved populations. The purpose of this study was to show the feasibility of delivering a peer education program for children with asthma and the effect of the program on indoor allergen levels in an inner-city population in Chicago. Overall, the program was well received. Baseline allergen levels were consistent with some previous studies in showing low levels of mite allergens and high levels of cockroach allergens, with 79.6% of samples having levels > 8 U/g. A total of 28.2% of samples had cat allergen levels > 2 microg/g, although only 9.7% of homes had cats, confirming previous reports that cat allergen is ubiquitous. Mold levels were seasonal, with the highest levels in the summer. Results from this study suggest that intervention programs should focus more on elimination of cockroaches than was previously appreciated, while minimizing the use of pesticides, and on identification of the sources of cat allergen. Structural and psychosocial issues in homes need to be addressed in future studies. This study has demonstrated the feasibility of delivering peer education in a inner-city population and highlighted the need for comprehensive intervention strategies addressing complex issues facing underserved neighborhoods.