PEDIATRICS Vol. 115 No. 5 May 2005, pp. 1254-1260 (doi:10.1542/peds.2004-0897)
Racial and Ethnic Differences in Asthma Diagnosis Among Children Who Wheeze
* Infant, Child, and Women's Health Studies Branch, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
Department of Pediatrics and Rand Health, University of California, Los Angeles/Rand Program on Latino Children With Asthma, Los Angeles, California
 |
ABSTRACT |
|---|
 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Background. Racial and ethnic disparities exist in reported childhood asthma prevalence, but it is unclear if disparities stem from true prevalence differences or a different likelihood of receiving a diagnosis from a health professional. Concern has been raised that asthma may be underdiagnosed, particularly among minority children who have more restricted access to high-quality health care.
Objective. To examine racial/ethnic differences among currently symptomatic children in acquiring an asthma diagnosis to determine if relative underdiagnosis among minorities exists. Children for whom no symptoms were reported (a group that includes those with well-controlled symptoms) were excluded from the analysis.
Methods. The 1999 National Health Interview Survey includes a nationally representative sample of children with reported wheezing symptoms. We included children 3 to 17 years old in the study and analyzed racial/ethnic differences in asthma diagnosis, controlling for young age, gender, parental education, single-parent household, central-city residence, region of residence, health insurance, having a usual place of care, and parent-reported severity of wheezing symptoms.
Results. Among those reported to have wheezed in the past year (n = 946), 83% of Puerto Rican, 71% of non-Hispanic black, and 65% of Mexican children were diagnosed with asthma compared with 57% of non-Hispanic white children. Using non-Hispanic white children as the reference group, the approximate adjusted relative risk for physician diagnosis of asthma given wheezing in the past year was 1.43 (95% confidence interval [CI]: 1.04, 1.63) for Puerto Rican, 1.22 (95% CI: 1.03, 1.37) for non-Hispanic black, and 1.19 (95% CI: 0.94, 1.39) for Mexican children. Minority children were reported to have greater severity of wheezing symptoms. Even after accounting for this increased severity, children in racial and ethnic minority groups were as or more likely to have a reported asthma diagnosis than non-Hispanic white children.
Conclusions. Our findings do not provide evidence for the hypothesis that symptomatic minority children are underdiagnosed with asthma compared with non-Hispanic white children. To the contrary, among currently symptomatic children, minority children were more likely to be diagnosed than non-Hispanic white children even after accounting for the higher wheezing severity among minority children.
Key Words: asthma • ethnic disparity • prevalence • racial differences • wheezing
Abbreviations: NHIS, National Health Interview Survey • NAEPP, National Asthma Education and Prevention Program
Many researchers have noted higher asthma prevalence rates among non-Hispanic black children, with prevalence rates ranging as high as 2 times those for non-Hispanic white children.1–5 These studies all defined asthma prevalence based on parental report of the child having asthma and/or receiving a doctor's diagnosis. However, the racial disparities in parent-reported asthma prevalence are small compared with those in asthma morbidity and mortality: black children are 
4 times as likely than white children to be hospitalized for or die as a result of asthma.6 Thus, there is some concern that national surveys that rely on parental report may underestimate the true prevalence difference between black and white children. One hypothesis is that inadequate health care access or lower-quality health care may result in undiagnosed asthma among minority groups and those living in urban areas.7–9 That is, although there is general concern that asthma is underdiagnosed and undertreated among symptomatic children,8,10 there is an added concern that minority children may be affected disproportionately.
Others argue that symptomatic poor and minority children receive health care in settings in which they are more likely to acquire an asthma diagnosis. For example, compared with white children, black children are more likely to visit the emergency department.11 Children assessed by unfamiliar providers in urgent care settings may be more likely to be labeled with asthma compared with children seen consistently by the same provider, who may wait to observe chronic symptoms before diagnosing asthma.12 Studies using local and national data in the late 1980s to early 1990s showed that although black children had a higher prevalence of asthma diagnosis than white children, black children were not more likely to wheeze than white children.2,4,13
It is unknown if symptomatic children from the various Hispanic subgroups experience differing rates of asthma diagnosis. Estimates of asthma rates among Hispanics have varied widely depending on which ethnic subgroups are included. Studies that have examined subgroups of Hispanics have found greatly increased prevalence among Puerto Rican children and the lowest asthma prevalence among Mexican children (refs 14–16; M.L., L.J.A., G. Flores, MD, and H. Morgenstern, PhD, unpublished data, 1997–2001).
We sought to revisit the question of whether white, black, Mexican, and Puerto Rican children who currently have reported wheezing symptoms have a different likelihood of receiving an asthma diagnosis when using recent national data. The supplemental asthma module in the 1999 National Health Interview Survey (NHIS) provides a nationally representative sample to examine the relationship between race/ethnicity and asthma diagnosis among symptomatic children.
|
METHODS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
The NHIS, a continuous national survey administered by the National Center for Health Statistics, collects data on the health characteristics of a representative sample of the US civilian noninstitutionalized population. General information is collected about persons in the household, and detailed health information is collected for a randomly selected sample adult and, if children are present, a sample child. For children <18 years of age, a knowledgeable adult (usually a parent) provides a proxy report of health conditions.17
This analysis included children 3 to 17 years of age. We excluded children <3 years of age because of the diagnostic uncertainty for respiratory conditions in very young children.18 Children of non-Hispanic white, non-Hispanic black, Puerto Rican, and Mexican ethnicity were included, but other racial and ethnic groups had insufficient sample sizes to obtain stable estimates and were excluded. In Tables 1 and 2, we examined the overall prevalence of wheezing and receiving an asthma diagnosis among the total sample of 8743. Then, we narrowed the sample to currently symptomatic children (n = 1006) by using a positive response to the question: "During the past 12 months, has your child had a wheezing or whistling sound in his/her chest?" This allowed us to determine if there were differences between racial/ethnic groups in asthma diagnosis among children currently experiencing wheezing. The NHIS does not contain data to examine the proportion of children diagnosed with asthma among those who had ever experienced symptoms during their lifetime and who may have had well-controlled symptoms at the time of the survey. Among currently symptomatic children, receiving an asthma diagnosis was determined by using positive responses to the question: "Has a doctor or other health professional ever told you that your child had asthma?"
|
|
We used multiple logistic regression to control for factors related to race/ethnicity and/or receiving an asthma diagnosis. Sociodemographic variables included family income (dichotomized as at or above $20000 vs below $20000), household structure (dichotomized as single-parent household versus
2 adults in the household), and highest level of parental education (dichotomized as no high school diploma versus high school graduation or equivalent). Almost 20% of observations did not have information about approximate family income. However, another variable in the NHIS, "family income at/above or below $20000," had missing information for <5% of observations. Therefore, we used the latter variable as a crude measure of poverty status. Those observations missing information for either family income at or above $20000 versus below $20000 or for parental education were excluded (N = 60), leaving 946 children in the study. Geographic variables included region of residence in the United States and central-city versus non–central-city residence. Having health insurance was used as a crude proxy for access to health care, dichotomized as any health insurance versus no health insurance. Respondents also were asked whether their child had a usual source of care when sick. We dichotomized responses as having a regular source of care versus no source or exclusive use of the emergency department for sick care. These variables were entered simultaneously into a logistic-regression model (model 1). We also considered the association between severity of wheezing symptoms and receiving an asthma diagnosis. Five measures of wheezing severity were available in the NHIS asthma module: (1) speech limited by wheezing; (2) wheezing during exercise; (3) frequency of wheezing; (4) sleep disturbance because of wheezing; and (5) activity limitation because of wheezing. These severity measures are highly correlated, and each one showed a similar relationship between degree of severity and receiving an asthma diagnosis. In analyses of the relationship between race/ethnicity and asthma diagnosis, we focused on activity limitation because it was the most global measure of wheezing severity and is most similar to the measures used to classify severity in the National Asthma Education and Prevention Program (NAEPP) clinical practice guidelines.19 Activity limitation was assessed by asking: "During the past 12 months, how much did you limit your child's usual activity due to wheezing or whistling?" The 5 possible responses ranged from "not at all" to "a lot." We dichotomized this variable as no limitation versus any limitation and included it in the regression model described above to assess the impact of wheezing severity on the association of race/ethnicity with asthma diagnosis (model 2).
We checked for collinearity by comparing standard errors between models including and omitting selected variables.20 Because the prevalence of the outcome (asthma diagnosis) was >10%, the odds ratio yielded by logistic regression overestimates relative risk. We approximated relative risk from odds ratios by using the method specified by Zhang and Yu21 and show these results in the tables. The actual odds ratios obtained from the model are shown in the Appendix.
Survey weights were used to calculate national estimates and confidence intervals. SUDAAN software (Research Triangle Institute, Research Triangle Park, NC) was used for all calculations and models to take account of the complex NHIS sampling design.
|
RESULTS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
Overall, 11.8% of children 3 to 17 years of age received an asthma diagnosis from a health care professional during their lifetime (Table 1). A significantly higher percentage of Puerto Rican children, 29.4%, received an asthma diagnosis compared with other racial/ethnic groups. Asthma diagnoses were more common also among children from low-income families compared with those from higher-income families. Overall, 10.5% of children were reported to have at least 1 wheezing episode in the past 12 months regardless of asthma diagnosis. Differences between race/ethnicity and income groups for recent wheezing were less marked than for lifetime asthma diagnosis but followed the same patterns: rates of recent wheezing were similar for non-Hispanic white and black children (10.7% and 11.3%), highest for Puerto Rican children (16.3%), and lowest for Mexican children (7.2%). Children in low-income families had a slightly increased rate of recent wheezing, but the difference did not reach statistical significance. Table 2 shows the cross tabulation between asthma diagnosis and current wheezing. Among children diagnosed with asthma, just over half had wheezed in the past year (587 of 1087). The group of diagnosed children with no current wheezing is heterogenous; it may include children who no longer have asthma, those with current asthma whose symptoms are well controlled, and those inappropriately labeled with asthma. It is unfortunate that we can neither distinguish between these subgroups nor estimate asthma diagnosis among those who ever had wheezing symptoms in their lifetime. Therefore, we focused the remainder of the analysis on the group of children with current symptoms to determine if minority children were less likely to receive an asthma diagnosis. Nearly one third (359 of 946) of the children who were reported to have wheezed in the past year had not received an asthma diagnosis in their lifetime.
Characteristics of this symptomatic sample of children are shown in Table 3. There were racial/ethnic differences for all characteristics except age. Children from minority racial/ethnic groups were more likely than non-Hispanic white children to have a single parent, have parents with less than a high school education, to have low family income, and to live in the central city of a metropolitan area. Puerto Rican and non-Hispanic white children were more likely than Mexican and non-Hispanic black children to have health insurance and to have a usual place to obtain sick care. Region of residence also differed: Puerto Rican children were much more likely to live in the Northeast, Mexican children in the West, and non-Hispanic black children in the South.
|
Among children who wheezed, minority children were more likely to have been diagnosed with asthma by a doctor or health professional. Although 57% of symptomatic non-Hispanic white children had received an asthma diagnosis, 71% of non-Hispanic black, 83% of Puerto Rican, and 65% of Mexican children received an asthma diagnosis (Table 4). Whether considering the approximate crude or adjusted relative risk (model 1), non-Hispanic black, Puerto Rican, and Mexican children had a higher likelihood of receiving an asthma diagnosis than non-Hispanic white children.
|
Next we addressed the question of whether the apparently higher rate of diagnosis is due to greater symptom severity among minority children. All 5 severity measures available in the NHIS indicate that minority children generally do have greater wheezing severity (data not shown). Compared with non-Hispanic white children, non-Hispanic black and Puerto Rican children were more likely to have wheezing severe enough to limit their speech; non-Hispanic black children were more likely to have wheezing during exercise; and non-Hispanic black and Mexican children were more likely to have >12 wheezing attacks in the previous 12 months. However, the overall differences between race/ethnicity groups were not statistically significant for these 3 measures. All groups of minority children were more likely than non-Hispanic white children to have their sleep disturbed by wheezing (P = .002) and have activity limitation due to wheezing (P = .01) (results for activity limitation are shown in Table 5).
|
We examined the percentage of diagnosed children within each response category of each of the 5 wheezing severity measures for each racial/ethnic group. As expected, there was a general trend toward a greater percentage of children diagnosed with asthma among groups with more severe symptoms, as seen for activity limitation (Table 5). Because a similar relationship exists between race/ethnicity, severity, and receiving an asthma diagnosis for all 5 measures, we included the most global measure, activity limitation, in the original logistic model (Table 4, model 2). Although activity limitation due to wheezing was measured on a 5-level scale, in the model it was dichotomized as any level of activity limitation versus no limitation. As shown in the last column of Table 4, adjusting for wheezing severity in addition to other possible confounders did not affect the finding that minority children with wheezing symptoms are as or more likely to receive an asthma diagnosis than non-Hispanic white children.
|
DISCUSSION |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
In this nationally representative sample, minority children with reported wheezing were as or more likely to be diagnosed with asthma compared with non-Hispanic white children even after taking into account possible confounders and the greater wheezing severity among minority children. Puerto Rican children had the highest prevalence of asthma diagnosis and wheezing and, among symptomatic children, the highest likelihood of receiving an asthma diagnosis.
Past studies have examined the overall prevalence of wheezing and asthma diagnosis/reported asthma in samples of white and minority children (as shown in Table 1) but generally have not compared the proportion receiving an asthma diagnosis among symptomatic children as shown in Table 4. Three patterns of association emerge from previous reports comparing wheezing symptoms and asthma diagnosis/reported asthma between race/ethnicity groups or children of varying socioeconomic status. The first pattern, observed among samples of children from Great Britain and New Zealand, is increased wheezing symptoms among children of lower socioeconomic status but no difference in reported asthma or reported asthma diagnosis compared with children of higher socioeconomic status.9,22,23 This result suggests higher rates of undiagnosed asthma among children in lower-income families. A second pattern is seen in 1 US study: higher prevalence of both persistent wheeze and reported asthma among minority children.5 The third pattern seen in other US studies suggests no relative underdiagnosis among minority children: smaller racial/ethnic and socioeconomic differences in wheezing than in reported asthma or asthma diagnosis.2,4,13,15,24,25 For example, in a sample of Illinois school children in grades 7 through 12, Fagan et al24 showed a relative risk of 1.1 for wheezing 4 times during the past year for black children compared with children of other race/ethnicity versus a relative risk of 1.5 of ever-diagnosed asthma. Cunningham et al2 observed an adjusted odds ratio of 1.0 for persistent wheeze for black compared with white children for a sample of 9- to 11-year-old Philadelphia school children versus an adjusted odds ratio of 2.3 for asthma diagnosis. Roberts13 used data from the National Health and Nutrition Examination Survey (1988–1994) to demonstrate that although black and white children 1 to 5 years old had similar wheezing prevalence, black children had twice the odds of having an asthma diagnosis. In contrast to these studies that examined the proportion of children with an asthma diagnosis separately from the proportion of those with wheezing symptoms, Schwartz et al4 presented data for asthma diagnosis among a group of children with current symptoms (similar to the first column in Table 2). Using a national sample of children (6 months to 11 years old) from the 1976–1980 National Health and Nutrition Examination Survey, they observed a relative risk of 1.5 for asthma diagnosis for symptomatic black children compared with symptomatic white children.
These studies show a higher rate of diagnosis and/or reported asthma for minority children using data predating the dramatic rise of asthma prevalence, data for a limited age group, or data for a local sample of children.2,4,13,24 Our results confirm this pattern using recent data for a nationally representative sample of children 3 to 17 years of age.
Possible Explanations for Higher Diagnosis Rates Among Symptomatic Minority Children
One explanation for different diagnosis rates between racial/ethnic groups may be greater symptom severity among minorities. However, in examining 5 NHIS severity measures, we found that symptomatic minority children were more likely to have an asthma diagnosis than white children regardless of severity level. We surmise that higher wheezing severity among minorities is unlikely to explain the higher likelihood of obtaining a diagnosis.
Another possible explanation for the discrepancy in diagnosis is cough-variant asthma in which the primary manifestation is chronic cough. In many cases, symptoms may progress over time to a more classic presentation with wheezing.26 However, we cannot speculate how examining children with chronic cough would have changed our observations, because those data are not available in the NHIS or other national surveys.
It is possible that given a similar clinical presentation, minority children are more likely to receive a diagnosis than non-Hispanic white children. For example, health practitioners who treat poor and minority populations or work in settings with less continuity of care, such as emergency departments, may be more likely to label children with asthma. Another possibility is that parents of minority children may be more likely to report wheezing because of an increased awareness of asthma and greater expectation of diagnosis. Black children may be more likely to have a family history of asthma compared with children of other races,24 which may contribute to greater asthma awareness. However, Roberts13 controlled for both family history and clinical presentation in his analysis and found that black children were still more likely to have a current asthma diagnosis compared with white children.
Puerto Rican Children Stand Out
Rates of wheezing and diagnosis are dramatically higher among Puerto Rican children regardless of wheezing severity level, which suggests that underdiagnosis is not an issue with Puerto Rican populations and that public health efforts could be geared toward better control and management. The disparate estimates of asthma among Hispanic subgroups (Puerto Rican children have the highest rates of symptoms and diagnosis and Mexican children have the lowest) highlights that combining Hispanic ethnicities into 1 group can obscure important differences in the asthma burden between children in the various subgroups.27
Limitations
Our estimates rely on proxy report. Understanding of the terms "wheezing" and "asthma" may vary between parents and clinicians and between parents of different sociodemographic and cultural backgrounds.28 Therefore, there may be misclassification that varies systematically by race/ethnicity. However, the consistently higher proportion of asthma diagnosis with greater wheezing severity across all racial/ethnic groups suggests that the NHIS measures of wheezing severity have validity.
As mentioned earlier, we are not able to comment on the racial/ethnic differences in receiving an asthma diagnosis among those with well-controlled symptoms. It is possible that there are racial/ethnic differences in symptom control and that non-Hispanic white children with an asthma diagnosis are more likely to have well-controlled symptoms and thereby have no wheezing symptoms in the past 12 months to report. However, among the group of children in the 1999 NHIS with an asthma diagnosis (n = 1087), the percentage of those without current symptoms was 46% for non-Hispanic white children, 45% for non-Hispanic black children, 54% for Puerto Rican children, and 46% for Mexican children. That is, among diagnosed children, minorities do not seem to be disproportionately affected by active symptoms.
We had a small sample of Puerto Rican children. Although estimates of asthma diagnosis and wheezing are statistically stable, the small sample size results in greater sampling error and uncertainty. Furthermore, it would have been informative to stratify by race and income, an option the small sample did not allow.
The 1999 NHIS wheezing question did not differentiate wheezing that occurred only during respiratory infections from persistent wheeze apart from colds. The former pattern is common among small children who may later stop manifesting wheezing symptoms and may no longer qualify for an asthma diagnosis. Also, as mentioned above, we cannot ascertain the prevalence of cough-variant asthma or the prevalence of cough in absence of a cold, because the NHIS contains no questions about chronic cough.
Finally, the NHIS does not have an objective independent measure of asthma severity (eg, pulmonary-function testing or peak-flow readings). Furthermore, the parent-reported severity measures in the NHIS differ from those used to classify asthma severity in the NAEPP clinical practice guidelines.19 These guidelines present 4 categories of asthma severity defined by symptom frequency, degree to which asthma exacerbations affect activity, duration of exacerbations, nighttime symptoms, and lung-function test results. Although parents were asked about symptom frequency and nighttime symptoms in the NHIS, the coded responses do not correlate with the categories presented in the NAEPP guidelines. The NHIS measure that most closely correlates with the NAEPP guidelines is activity limitation, as mentioned above. We also were prevented from adhering closely to the severity categories in the NAEPP guidelines because they require categorization of severity before treatment; however, there is no way to adjust for medical management among NHIS respondents. Additionally, the parent-reported wheezing severity measures in the NHIS could be affected by numerous factors including whether a child was ever labeled with an asthma diagnosis.
Implications for Interpreting Disparities
Regional differences in asthma prevalence may not be completely related to environmental factors such as air pollution or climate but may be affected also by differences in health care delivery and the process of obtaining an asthma diagnosis. For example, studies examining inner-city children in the Northeast find dramatically higher rates of reported asthma compared with national averages.15 In many cases, this may be driven by both the higher prevalence of asthma among Puerto Rican children and the concentration of the Puerto Rican population in the Northeast.15 To the extent that reported asthma is based on receiving an asthma diagnosis, caution must be exercised in ascribing the higher rates of asthma found in Northeast urban centers to specific exposures or the urban environment without taking ethnicity or a potentially different likelihood of receiving an asthma diagnosis into account. Furthermore, because of changing awareness of asthma, diagnostic transfer over time (labeling symptoms as asthma that were diagnosed previously as other conditions), and changes in medical practice, the relationship between sociodemographic factors and receiving an asthma diagnosis may change over time and may vary between the different systems of health care delivery in each region or country.
In examining racial disparities in asthma burden among children, it is apparent that disparities in morbidity and mortality overshadow those in reported asthma prevalence.27,29,30 The relatively small differences in reported asthma prevalence that do exist between black and white children are reduced or eliminated after adjusting for confounders such as socioeconomic status or urban residence.1,31,32 In contrast, compared with white children, black children have asthma hospitalization rates that are 4 times as high and are >4 times as likely to die as a result of asthma.6 Asthma prevalence and morbidity have been shown to be higher for Puerto Rican children compared with other Hispanic subgroups (refs 16 and 33–35; M.L., L.J.A., G. Flores, MD, H. Morgenstern, PhD, unpublished data 1997–2001), and age-adjusted asthma mortality for Puerto Rican people of all ages is of the same high magnitude as that among non-Hispanic black people.27 Many studies have demonstrated that these large disparities in morbidity and mortality may be due in part to differences in health care access, use, and quality.9,33,36–40 Our results suggest that morbidity and mortality disparities cannot be attributed to undermeasured asthma prevalence in minorities and that health care factors and other possible explanations should be pursued.
|
CONCLUSIONS |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
We found no evidence to suggest that symptomatic minority children are underdiagnosed with asthma compared with non-Hispanic white children. Determining factors in the process of acquiring an asthma diagnosis may be necessary to better understand racial and ethnic disparities in asthma prevalence.
|
|
FOOTNOTES |
|---|
Accepted Aug 31, 2004.
Address correspondence to Lara J. Akinbami, MD, National Center for Health Statistics, Infant, Child and Women's Health Studies Branch, 3311 Toledo Rd, Room 6117, Hyattsville, MD 20782. E-mail: lea8{at}cdc.gov
No conflict of interest declared.
|
REFERENCES |
|---|
|
TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
- Weitzman M, Gortmaker S, Sobol A. Racial, social, and environmental risks for childhood asthma.
Am J Dis Child. 1990;144
:1189
–1194
[Abstract/Free Full Text] - Cunningham J, Dockery DW, Speizer FE. Race, asthma, and persistent wheeze in Philadelphia schoolchildren.
Am J Public Health. 1996;86
:1406
–1409
[Abstract/Free Full Text] - Gergen PJ, Mullally DI, Evans R III. National survey of prevalence of asthma among children in the United States, 1976 to 1980.
Pediatrics. 1988;81
:1
–7
[Abstract/Free Full Text] - Schwartz J, Gold D, Dockery DW, Weiss ST, Speizer FE. Predictors of asthma and persistent wheeze in a national sample of children in the United States. Association with social class, perinatal events, and race. Am Rev Respir Dis. 1990;142 :555 –562[Web of Science][Medline]
- Gold DR, Rotnitzky A, Damokosh AI, Ware JH, Speizer FE, Ferris BG, Jr et al. Race and gender differences in respiratory illness prevalence and their relationship to environmental exposures in children 7 to 14 years of age. Am Rev Respir Dis. 1993;148 :10 –18[Web of Science][Medline]
- Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality.
Pediatrics. 2002;110
:315
–322
[Abstract/Free Full Text] - Joseph CL, Foxman B, Leickly FE, Peterson E, Ownby D. Prevalence of possible undiagnosed asthma and associated morbidity among urban schoolchildren. J Pediatr. 1996;129 :735 –742[CrossRef][Web of Science][Medline]
- Yeatts K, Davis KJ, Sotir M, Herget C, Shy C. Who gets diagnosed with asthma? Frequent wheeze among adolescents with and without a diagnosis of asthma.
Pediatrics. 2003;111
:1046
–1054
[Abstract/Free Full Text] - Duran-Tauleria E, Rona RJ, Chinn S, Burney P. Influence of ethnic group on asthma treatment in children in 1990–1: national cross sectional study.
BMJ. 1996;313
:148
–152
[Abstract/Free Full Text] - Yeatts K, Shy C, Sotir M, Music S, Herget C. Health consequences for children with undiagnosed asthma-like symptoms.
Arch Pediatr Adolesc Med. 2003;157
:540
–544
[Abstract/Free Full Text] - Joseph CL, Havstad SL, Ownby DR, Johnson CC, Tilley BC. Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications. J Allergy Clin Immunol. 1998;101 :484 –490[CrossRef][Web of Science][Medline]
- Gergen P. Social class and asthma—distinguishing between the disease and the diagnosis.
Am J Public Health. 1996;86
:1361
–1362
[Free Full Text] - Roberts EM. Racial and ethnic disparities in childhood asthma diagnosis: the role of clinical findings. J Natl Med Assoc. 2002;94 :215 –223[Medline]
- Carter-Pokras OD, Gergen PJ. Reported asthma among Puerto Rican, Mexican-American, and Cuban children, 1982 through 1984.
Am J Public Health. 1993;83
:580
–582
[Abstract/Free Full Text] - Crain EF, Weiss KB, Bijur PE, Hersh M, Westbrook L, Stein RE. An estimate of the prevalence of asthma and wheezing among inner-city children.
Pediatrics. 1994;94
:356
–362
[Abstract/Free Full Text] - Beckett WS, Belanger K, Gent JF, Holford TR, Leaderer BP. Asthma among Puerto Rican Hispanics: a multi-ethnic comparison study of risk factors. Am J Respir Crit Care Med. 1996;154 :894 –899[Abstract]
- Blackwell DL, Tonthat L. Summary Health Statistics for U.S. Children: National Health Interview Survey, 1999. Vital Health Stat 10. Issue 210. Hyattsville, MD: National Center for Health Statistics; 2003
- Martinez FD, Wright AL, Taussig LM, Holberg CJ, Halonen M, Morgan WJ. Asthma and wheezing in the first six years of life. The Group Health Medical Associates.
N Engl J Med. 1995;332
:133
–138
[Abstract/Free Full Text] - National Institutes of Health, National Heart Lung and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 97-4051. Bethesda, MD: National Institutes of Health; 1997
- Hosmer DW, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley & Sons, Inc; 1989
- Zhang J, Yu KF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes.
JAMA. 1998;280
:1690
–1691
[Abstract/Free Full Text] - Mitchell EA, Stewart AW, Pattemore PK, Asher MI, Harrison AC, Rea HH. Socioeconomic status in childhood asthma.
Int J Epidemiol. 1989;18
:888
–890
[Abstract/Free Full Text] - Duran-Tauleria E, Rona RJ. Geographical and socioeconomic variation in the prevalence of asthma symptoms in English and Scottish children.
Thorax. 1999;54
:476
–481
[Abstract/Free Full Text] - Fagan JK, Scheff PA, Hryhorczuk D, Ramakrishnan V, Ross M, Persky V. Prevalence of asthma and other allergic diseases in an adolescent population: association with gender and race. Ann Allergy Asthma Immunol. 2001;86 :177 –184[Web of Science][Medline]
- Yeatts KB, Shy CM. Prevalence and consequences of asthma and wheezing in African-American and white adolescents. J Adolesc Health. 2001;29 :314 –319[CrossRef][Web of Science][Medline]
- Hannaway PJ, Hopper GD. Cough variant asthma in children.
JAMA. 1982;247
:206
–208
[Abstract/Free Full Text] - Homa DM, Mannino DM, Lara M. Asthma mortality in U.S. Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990–1995.
Am J Respir Crit Care Med. 2000;161
:504
–509
[Abstract/Free Full Text] - Cane RS, Ranganathan SC, McKenzie SA. What do parents of wheezy children understand by "wheeze?
" Arch Dis Child. 2000;82
:327
–332
[Abstract/Free Full Text] - Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma—United States, 1980–1999. MMWR Surveill Summ. 2002;51(1) :1 –13
- Akinbami LJ, LaFleur BJ, Schoendorf KC. Racial and income disparities in childhood asthma in the United States. Ambul Pediatr. 2002;2 :382 –387[CrossRef][Web of Science][Medline]
- Aligne CA, Auinger P, Byrd RS, Weitzman M. Risk factors for pediatric asthma. Contributions of poverty, race, and urban residence.
Am J Respir Crit Care Med. 2000;162
:873
–877
[Abstract/Free Full Text] - Litonjua AA, Carey VJ, Weiss ST, Gold DR. Race, socioeconomic factors, and area of residence are associated with asthma prevalence. Pediatr Pulmonol. 1999;28 :394 –401[CrossRef][Web of Science][Medline]
- Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid.
Pediatrics. 2002;109
:857
–865
[Abstract/Free Full Text] - Ledogar RJ, Penchaszadeh A, Garden CC, Iglesias G. Asthma and Latino cultures: different prevalence reported among groups sharing the same environment.
Am J Public Health. 2000;90
:929
–935
[Abstract/Free Full Text] - Celedon JC, Sredl D, Weiss ST, Pisarski M, Wakefield D, Cloutier M. Ethnicity and skin test reactivity to aeroallergens among asthmatic children in Connecticut.
Chest. 2004;125
:85
–92
[Abstract/Free Full Text] - Halfon N, Newacheck PW. Childhood asthma and poverty: differential impacts and utilization of health services.
Pediatrics. 1993;91
:56
–61
[Abstract/Free Full Text] - St Peter RF, Newacheck PW, Halfon N. Access to care for poor children. Separate and unequal? JAMA. 1992;267 :2760 –2764
- Finkelstein JA, Brown RW, Schneider LC, et al. Quality of care for preschool children with asthma: the role of social factors and practice setting.
Pediatrics. 1995;95
:389
–394
[Abstract/Free Full Text] - Homer CJ, Szilagyi P, Rodewald L, et al. Does quality of care affect rates of hospitalization for childhood asthma?
Pediatrics. 1996;98
:18
–23
[Abstract/Free Full Text] - Lozano P, Connell FA, Koepsell TD. Use of health services by African-American children with asthma on Medicaid.
JAMA. 1995;274
:469
–473
[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
This article has been cited by other articles:
|
|
 |
|
  D. Crocker, C. Brown, R. Moolenaar, J. Moorman, C. Bailey, D. Mannino, and F. Holguin Racial and Ethnic Disparities in Asthma Medication Usage and Health-Care Utilization: Data From the National Asthma Survey Chest, October 1, 2009; 136(4): 1063 - 1071. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. V. James and S. Rosenbaum Paying for Quality Care: Implications for Racial and Ethnic Health Disparities in Pediatric Asthma Pediatrics, March 1, 2009; 123(Supplement_3): S205 - S210. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Panico, M. Bartley, M. Marmot, J. Y Nazroo, A. Sacker, and Y. J Kelly Ethnic variation in childhood asthma and wheezing illnesses: findings from the Millennium Cohort Study Int. J. Epidemiol., October 1, 2007; 36(5): 1093 - 1102. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. T. Cohen, G. J. Canino, H. R. Bird, S. Shen, B. A. Rosner, and J. C. Celedon Area of Residence, Birthplace, and Asthma in Puerto Rican Children Chest, May 1, 2007; 131(5): 1331 - 1338. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Choudhry, E. G. Burchard, L. N. Borrell, H. Tang, I. Gomez, M. Naqvi, S. Nazario, A. Torres, J. Casal, J. C. Martinez-Cruzado, et al. Ancestry-Environment Interactions and Asthma Risk among Puerto Ricans Am. J. Respir. Crit. Care Med., November 15, 2006; 174(10): 1088 - 1093. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. M. Davis, R. Kreutzer, M. Lipsett, G. King, and N. Shaikh Asthma Prevalence in Hispanic and Asian American Ethnic Subgroups: Results From the California Healthy Kids Survey Pediatrics, August 1, 2006; 118(2): e363 - e370. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Randolph Racial and Ethnic Differences in Asthma Diagnosis Among Children Who Wheeze Pediatrics, August 1, 2006; 118(Supplement_1): S39 - S40. [Abstract] [PDF]
|
|
|
|
|
|
G. M. Hunninghake, S. T. Weiss, and J. C. Celedon Asthma in Hispanics Am. J. Respir. Crit. Care Med., January 15, 2006; 173(2): 143 - 163. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
