PEDIATRICS Vol. 117 No. 1 January 2006, pp. 43-53 (doi:10.1542/peds.2004-1714)
ARTICLE |
Heterogeneity of Childhood Asthma Among Hispanic Children: Puerto Rican Children Bear a Disproportionate Burden
a University of California, Los Angeles/RAND Program on Latino Children with Asthma, Los Angeles, California
b Centers for Disease Control and Prevention, Hyattsville, Maryland
c Center for the Advancement of Underserved Children, Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
d University of Michigan School of Public Health, Ann Arbor, Michigan
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. To estimate differences in asthma prevalence among Hispanic subgroups and non-Hispanic children living in the United States and to explore the association between these differences and risk factors.
METHODS. Weighted logistic regression analyses of merged 1997 to 2001 National Health Interview Survey data were used to estimate the prevalence of asthma diagnosis and asthma attacks in a sample of 46511 children (age: 2–17 years) living in the 50 states and the District of Columbia.
RESULTS. Puerto Rican children had the highest prevalence of lifetime asthma (26%) and recent asthma attacks (12%), compared with non-Hispanic black children (16% and 7%, respectively), non-Hispanic white children (13% and 6%, respectively), and Mexican children (10% and 4%, respectively). Adjustment for asthma risk factors did not change these comparisons appreciably. Compared with non-Hispanic white children, the adjusted odds ratios (ORs) for a lifetime asthma diagnosis were 2.33 (95% confidence interval [CI]: 1.90–2.84) for Puerto Rican children, 1.16 (95% CI: 1.04–1.29) for non-Hispanic black children, and 0.90 (95% CI: 0.79–1.03) for Mexican children. Birthplace influenced the association between ethnicity and lifetime asthma diagnosis differently for Puerto Rican and Mexican children. Compared with United States-born non-Hispanic white children with United States-born parents, the adjusted ORs were 1.95 (95% CI: 1.48–2.57) for Puerto Rican children in families with the child and parent(s) born in the 50 states/District of Columbia and 2.50 (95% CI: 1.51–4.13) for island-born Puerto Rican children with island-born parents. The corresponding adjusted ORs for Mexican children were 1.05 (95% CI: 0.90–1.22) for families born in the 50 states/District of Columbia and 0.43 (95% CI: 0.29–0.64) for those born in Mexico. The results were similar for recent asthma attacks.
CONCLUSIONS. The appreciably higher asthma morbidity rates experienced by Puerto Rican children cannot be explained by sociodemographic and other risk factors measured in the National Health Interview Survey. The heterogeneity of asthma among Hispanic subgroups should be considered in developing effective public health prevention and intervention strategies.
Key Words: asthma • Hispanic • Latino • Puerto Rican • Mexican
Abbreviations: NHIS—National Health Interview Survey • OR—odds ratio • CI—confidence interval
Poor and minority children in the United States suffer a disproportionately high burden of asthma.1–7 Multiple studies document increased asthma prevalence, health care utilization, and mortality rates among non-Hispanic black children,1,5,6,8–10 but less is known about Hispanic children with asthma, particularly regarding differences among children of Puerto Rican, Mexican, Cuban, or other Hispanic heritage.11–14
Mounting evidence demonstrates that Hispanic/Latino individuals (hereafter referred to as Hispanic, to be consistent with US Census nomenclature) are a heterogeneous group, with varying health status and associated risk factors.15–17 Among Hispanic children, Puerto Rican children have higher rates of chronic illness and low birth weight.18,19 Asthma studies to date in Hispanic populations confirm this pattern, with Puerto Rican individuals living in the 50 states and the District of Columbia having higher asthma morbidity and mortality rates than other Hispanic subgroups.11–14,20,21 Less comparable information is available about persons with asthma living on the island of Puerto Rico.22,23 In contrast, Mexican children living in the 50 states and the District of Columbia have been shown to have lower morbidity rates, despite having risk factors for poor health.11,18,24
Since the dramatic increase in asthma prevalence over the past 2 decades, prevalence differences among Hispanic subgroups of children in the United States have not been analyzed in detail.6,25 Although a few studies have explored some possible explanatory factors for these differences (eg, socioeconomic, access to care, or environmental factors), no study to date, to the best of our knowledge, has evaluated a wide range of possible risk factors simultaneously.11,12 In addition, the observation of better-than-expected health indicators for certain Hispanic groups, compared with other populations that experience poverty, low education, and problems accessing health care,15 has not been explored fully for asthma. The National Health Interview Survey (NHIS) provides an opportunity to analyze multiple factors that may be associated with differences in asthma burdens among different Hispanic subgroups.
We used the 1997 to 2001 NHIS to obtain adequate sample sizes for analysis of asthma prevalence among Puerto Rican, Mexican, Cuban, and Dominican children. In particular, we hypothesized that Puerto Rican children would have an ethnic-specific predisposition for high asthma burden after adjustment for possible confounding factors. We also analyzed the association between asthma prevalence and place of birth of the child and parents, as a crude proxy of acculturation, to determine whether the association varied among Hispanic subgroups.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The NHIS is a survey of a representative sample of the US civilian population in the 50 states and the District of Columbia and excludes the island of Puerto Rico and other US territories and protectorates. Detailed health information is collected in a household interview 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. To obtain adequate sample sizes for analysis of Hispanic subgroups, we grouped data from 1997 to 2001. The analysis included children 2 to 17 years of age (n = 59451). We excluded children <2 years of age because of diagnostic uncertainty regarding respiratory conditions among very young children.26 Survey weights, which take nonresponse into account, were used to calculate national estimates and confidence intervals (CIs) with SUDAAN software.27
Lifetime asthma diagnosis rates were determined on the basis of responses to the question, "Has a doctor or other health professional ever told you that your child had asthma?" The 12-month period prevalence of asthma attack was estimated on the basis of positive responses for lifetime asthma diagnosis and positive responses to the question, "During the past 12 months, has your child had an episode of asthma or an asthma attack?" The precision of crude estimates of lifetime asthma diagnosis rates and asthma attack prevalence across racial/ethnic groups was evaluated with SEs.
We analyzed the association between these outcomes and available covariates, ie, known or possible risk factors for asthma selected on the basis of previous studies.6,8,14,28–34 Demographic variables included gender, young age (2–5 years versus 
5 years), and race/ethnicity (non-Hispanic white, non-Hispanic black, Puerto Rican, Mexican, Cuban, Dominican, other Hispanic, or other non-Hispanic [all other races/ethnicities]). Hereafter we refer to children of Mexican heritage (whether born in the United States or in Mexico) as Mexican and children of Puerto Rican heritage (whether born on the island of Puerto Rico or in the 50 states and the District of Columbia) as Puerto Rican, and we refer similarly to Cuban and Dominican children. We refer to non-Hispanic white children and non-Hispanic black children as white and black, respectively. Sociodemographic variables included family income, household structure (single-parent household versus 2 adults in the household), and highest level of education of all parents in the household (no high school diploma versus high school diploma or higher). We excluded 2534 children with missing information regarding parental education. Nearly 20% of families did not report approximate family income. However, <5% of observations were missing a response to the question, "Is your family income above or below $20000?" Our initial analyses did not differ appreciably with the use of approximate family income to categorize families as poor versus nonpoor or the use of family income above versus below $20000. Therefore, we used family income above/below $20000 as a proxy for poverty, to ensure adequate sample sizes for Hispanic subgroups, and excluded children with missing information on this variable (n = 2439).
Behavioral/environmental factors included measures of overweight and exposure to tobacco smoke. The NHIS includes proxy-reported data on height and weight, which were used to calculate BMI. To remove extreme outliers, we used Epi Info 2002 software35 to calculate BMI z scores according to age and gender. According to the World Health Organization Fixed Exclusion Range,36 observations with BMI z scores of less than –4.0 or >5.0 were excluded, as were those missing either height or weight data (n = 7967). BMI was categorized as >95th percentile, >85th to 95th percentile, 5th to 85th percentile, or <5th percentile.37 Height was also included in the model, because BMI alone may not characterize adequately the joint relationships between health outcomes and body composition and body size.38 The NHIS does not include a question about smoking for all persons in the household. However, the sample adult is asked whether he or she smokes cigarettes currently. Children living with a smoking sample adult were classified as "exposed" to tobacco smoke. Children for whom the sample adult did not smoke were classified as having "unknown exposure," because there might have been other adult smokers in the household. To evaluate this classification, we analyzed data for children living with only 1 adult (ie, the sample adult). This sensitivity analysis yielded similar results and increased our confidence that the group with unknown exposure represented predominantly children not exposed to cigarette smoke.
We included 2 crude indicators of acculturation. The first indicator was whether the interview was conducted completely in Spanish. Unfortunately, the NHIS contains no question about the primary language spoken in the household or about the parent's English proficiency. The second indicator was place of birth of the parent(s) and the sample child, with 3 categories, ie, child and parent(s) born in the 50 states/District of Columbia, child and parent(s) born in the 50 states/District of Columbia and outside the 50 states/District of Columbia (any combination), and both child and parent(s) born outside the 50 states/District of Columbia. For each Hispanic subgroup, <1% of children were born neither in the 50 states/District of Columbia nor in the country of their ethnic origin. That is, for Hispanic children, being born outside the 50 states/District of Columbia represented predominantly being born in Puerto Rico for Puerto Rican children, Mexico for Mexican children, Cuba for Cuban children, and the Dominican Republic for Dominican children.
Geographic variables included region of residence in the mainland United States (Northeast, South, Midwest, or West) and central city versus non-central city residence. Having health insurance was used as a crude proxy for access to health care and was dichotomized. Respondents were also asked whether their child had a usual source of care when sick; these responses were also dichotomized. Children who used the emergency department as their usual source of sick care were considered not to have a usual source.
After all exclusions, the final sample size was 46511 (an overall decrease of 22%). No imputation methods were applied to missing data. Observations excluded for missing or implausible information for BMI, parental education, and family income were more likely to be for children of racial/ethnic minority groups. The white sample was decreased by 15%, whereas the sample reduction among minority groups was 28% for black, 26% for Puerto Rican, 35% for Mexican, 23% for Cuban, and 29% for Dominican. Because of the small sample sizes for Cuban and Dominican children, there is a higher level of uncertainly associated with the estimates for these groups and estimates are less reliable.
All variables were entered simultaneously into a logistic regression model by using PROC RLOGIST in SUDAAN software.27 We checked for colinearity by comparing SEs between models that included or omitted selected variables. Interactions between race/ethnicity and other covariates were investigated with product terms. The only interaction that changed the interpretation for race/ethnicity and the outcomes was place of birth of the child and parent(s). Odds ratios (ORs) and 95% CIs were estimated for race/ethnicity and place of birth strata with logistic regression.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Substantial baseline sociodemographic differences existed among racial/ethnic groups in this nationally representative sample of children living in the 50 states and the District of Columbia (Table 1). Compared with white children, black, Puerto Rican, and Dominican children were more likely to live in a single-parent household, have parents who were not high school graduates, have low family income, be overweight, lack health insurance, have no usual source of sick care, and live in a central city. Mexican children were approximately as likely to have a single parent as were white children, but they were the most likely of any group to have parents with less than a high school education, to be uninsured, and to have no source of sick care. Mexican and Dominican children had the lowest rates of adult smokers in the household. Among Hispanic children, Cuban children had characteristics most similar to those of white children.
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There were marked differences in region of residence. Black children and Cuban children lived predominantly in the South, Puerto Rican and Dominican children in the Northeast, and Mexican children in the West. When the place of birth of the child and parent(s) was examined, the majority of white and black family units consisted of a child and parent(s) born in the 50 states/District of Columbia, whereas a minority of Hispanic family units consisted of a child and parent(s) born in the 50 states/District of Columbia.
Overall, 13.1% of children had received a diagnosis of asthma in their lifetimes and 5.9% had experienced an asthma attack in the previous 12 months. Table 2 shows the prevalence of a lifetime asthma diagnosis and recent asthma attack according to race/ethnicity. The familiar pattern of higher asthma prevalence among black children, compared with white children, was seen, but the most striking finding was that Puerto Rican children had dramatically higher rates of a lifetime asthma diagnosis and asthma attacks compared with all other children. Cuban and Dominican children had a lifetime asthma diagnosis prevalence similar to that of black children and asthma attack prevalence comparable to that of white children. Mexican children had the lowest lifetime asthma diagnosis rates and asthma attack prevalence compared with all other children.
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Table 3 shows logistic regression results for lifetime asthma diagnosis and Table 4 shows results for recent asthma attack, with white children as the reference group. The crude (unadjusted) ORs for black children for lifetime asthma diagnosis and recent asthma attack were attenuated by adjustment for the measured covariates. In contrast, the adjusted ORs for all Hispanic subgroups were either accentuated or unaffected. Puerto Rican children had the highest burden of asthma, in both crude and adjusted analyses, and Mexican children had the lowest. For both models, the associations between the covariates and the outcome variables were as expected. Having some or all family members born outside the 50 states/District of Columbia was also associated with lower prevalence of both lifetime asthma diagnosis and recent asthma attack.
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To examine more thoroughly the association between race/ethnicity and asthma prevalence according to birthplace, we entered an interaction term for race/ethnicity and place of birth into the models shown in Tables 3 and 4. Table 5 and Fig 1 show results for a lifetime asthma diagnosis. For Mexican, other Hispanic, and non-Hispanic white children, being born outside the United States to foreign-born parents was associated with greatly reduced odds of receiving an asthma diagnosis. In contrast, island-born Puerto Rican children had increased odds of a lifetime asthma diagnosis. A trend similar to that for Puerto Rican children was seen among Cuban children. Table 6 and Fig 2 show almost-identical patterns for recent asthma attacks.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Two important findings emerge from our study of racial/ethnic disparities in childhood asthma outcomes. First, Puerto Rican children had the highest lifetime asthma and recent attack prevalence of all US racial/ethnic groups we examined. Even after accounting for their higher prevalence of measured asthma risk factors, including poverty, household smoking, single parenthood, and obesity, compared with other Hispanic children, Puerto Rican children were twice as likely as non-Hispanic white children to be reported to ever have had asthma. Although Puerto Rican children had socioeconomic characteristics similar to those of black children, the increased prevalence among Puerto Rican children was not explained by several other factors that accounted for prevalence disparities between white and black children in previous studies.39–41 Furthermore, the greatest heterogeneity existed between groups within the Hispanic population (Puerto Rican children had the highest prevalence and Mexican children the lowest prevalence) and not between white and black races, which has been the main focus of research on racial/ethnic disparities in childhood asthma to date.
Second, parental reports of childhood asthma prevalence were related to the place of birth of the parent and child. Stratified analyses showed that, for black, white, Mexican, and perhaps Dominican children, asthma prevalence was lower among children born outside the 50 states/District of Columbia than among children born in the United States. In contrast, for Puerto Rican and perhaps Cuban children, asthma prevalence was higher among those born outside the 50 states/District of Columbia. However, interpretation of the results for Cuban and Dominican children is limited by small sample sizes. Because Puerto Rican and Mexican children are the largest Hispanic subgroups and because they define the extremes of asthma prevalence, focusing on the association between place of birth and asthma outcomes for these groups may lend insight into the impact of acculturation on asthma outcomes. Klinnert et al42 described a possible protective effect of lower acculturation, defined as a lower prevalence of several biological and psychosocial asthma risk factors, among a group of predominantly Mexican American children with asthma. Our findings support this pattern among Mexican children but show the opposite effect for Puerto Rican children. Therefore, the finding of a decreased risk of certain health conditions among some Hispanic children born outside the 50 states/District of Columbia15,18,42 is not generalizable to Puerto Rican children with asthma.
Although place of birth is only a crude proxy for acculturation, our findings suggest that acculturation is an important factor to consider in understanding asthma diagnosis, risk factors, and the effectiveness of clinical and public health interventions. One would expect that acculturation, the process of cultural transition in which an individual is exposed to and adopts characteristic ways of a foreign culture,15 would be somewhat different for Puerto Rican children. For example, in contrast to other Hispanic children born outside the 50 states/District of Columbia, island-born Puerto Rican children are US citizens and have fewer potential barriers to the health care system, such as fewer problems with language and obtaining insurance, than do foreign-born Mexican children.43 The possible beneficial effect of acculturation among Puerto Rican children was also described by Pachter and Weller,44 who found that acculturation among Puerto Rican children could be associated with greater compliance with medical regimens.
Why is the burden of asthma greatest among Puerto Rican children? We interpret most of the differences in reported prevalence as actual differences in the true incidence of disease. Our overarching hypothesis for future research is an ethnic group-specific genetic predisposition among Puerto Rican children that interacts with early life physical and social environmental exposures (eg, molds and/or family psychosocial stressors).45,46 Exposures that may contribute to the higher prevalence of asthma among Puerto Rican children include their lower rates of breastfeeding and higher rates of low birth weight, compared with other groups.47–49 Because our results also suggest that island-born Puerto Rican children have a higher prevalence of asthma than do Puerto Rican children born in the 50 states/District of Columbia, birth and residence in the island of Puerto Rico may expose children with a strong genetic predisposition toward asthma to certain environmental risk factors.
Factors other than true differences in disease expression could also account for part of the large observed differences between the Puerto Rican group and other groups. An ascertainment bias may be present. Perhaps children of Puerto Rican origin have a greater severity of asthma and, given the recurrent nature of asthma among children, it is possible that Mexican or other Hispanic subgroups have less opportunity to have an asthma diagnosis made by a provider. There may also be other reasons for differences between ethnic groups in acquiring an asthma diagnosis, such as differential recognition of disease symptoms by health care professionals. Prevalence measures depend on parental reports, and there may also be differences in the accuracy and recall of parental reporting of a child asthma diagnosis, related to racial/ethnic group-specific or acculturation-related differences in knowledge or awareness of asthma.
Our results showed that being insured and having a source of sick care were associated with higher reported asthma prevalence, which suggests that contact with the health care system is related to a higher likelihood of being diagnosed as having asthma. Acquiring an asthma diagnosis is likely a multifactorial issue, with acculturation, health care delivery, and behavioral factors influencing decisions to seek care and physician labeling of conditions. In general, speculation about what unmeasured factors (eg, health care, disease severity, environmental, genetic/biological, or behavioral factors) could explain the excess asthma prevalence in the Puerto Rican group is difficult, because it is challenging to establish a priori which asthma risk factors might differ systematically between the Puerto Rican group and all other Hispanic and non-Hispanic groups.
Our study has several limitations. Parental reporting of asthma diagnoses and symptoms might differ from a clinical assessment. Although previous studies showed that agreement between parental reporting and medical records is among the highest levels for asthma, the overall agreement is only moderate.50 Because the NHIS is not administered outside the 50 states and the District of Columbia, we were not able to compare the effect of birth and residence in Puerto Rico or Mexico. The NHIS lacks data about other important asthma risk factors, such as maternal history of asthma, indoor and outdoor environmental exposures, and medical examination findings (eg, child atopy measured with skin tests),51,52 which might have explained the marked differences among the groups. A national data set that includes a broader set of asthma risk factors, the National Examination and Nutrition Survey, does not have large enough sample sizes for evaluation of differences among Hispanic subgroups, specifically Puerto Rican children. The NHIS also does not contain information about hospitalizations for treatment of asthma and, although information about emergency department use was available, the sample sizes were too small for analysis of data for smaller ethnic groups. In addition, some bias might have been introduced by the differential rates of certain missing data in the NHIS data set across ethnic groups. The direction and degree of this possible bias, however, are difficult to estimate.
Furthermore, throughout the study period (1997–2001), the NHIS implemented changes to improve the translation and cultural adaptation methods used in the field, such as following a documented process for translation and validation of the survey, instead of depending on interviewers to perform translations in the field as needed (D. Rose, PhD, verbal communication, 2002). To the best of our knowledge, possible differences in how Hispanic subgroups interpret the NHIS asthma questions have not been evaluated. In contrast to other studies in which language was found to be a marker for acculturation or other important health characteristics and processes,42,53–55 we found that lifetime prevalence and recent attack prevalence were not related to interview language. It may be that there is indeed no relationship between language and asthma outcomes, that the measure of language in the NHIS assesses English proficiency and language acculturation inadequately, and/or that possible measurement error was introduced from translation problems in the earlier years of the study period. Given the stated limitations of the language variable, we were careful not to overinterpret associations with other variables.
Our findings have implications for clinicians and health care delivery organizations. Increased awareness of the higher risk of asthma among Puerto Rican children could facilitate better targeting of intervention resources. Health care providers could be more vigilant and aggressive in making sure that Puerto Rican children receive appropriate asthma treatment, follow-up care, and education about asthma triggers and prevention strategies. Underuse of preventive antiinflammatory medications was reported in studies of mostly Puerto Rican populations.56,57 Asthma studies also showed that continuity of care, family beliefs and compliance with therapy, and the use of ethnomedical therapies can vary among Hispanic subgroups.44,58–60 Moreover, health care organization policies promoting cultural competence were shown to be associated with better quality of care among children with asthma.61 Therefore, cultural paradigms need to be considered in the design and implementation of successful clinical and educational interventions. Specifically, in geographic areas with a high density of Puerto Rican individuals, health care provider organizations and public health agencies could find that tailoring programs to the specific needs of the Puerto Rican population is an effective population-based strategy. Similarly, the difference in prevalence between foreign-born and United States-born Mexican children could prompt vigilance among public health and health care professionals regarding a possible lack of awareness of asthma and less access to the health care system among groups with lower levels of acculturation.
Although the Centers for Disease Control and Prevention and other organizations are starting to address the need for improved asthma surveillance among Hispanic subgroups, more comparable data for evaluation of differences in risk and prognostic factors among geographically diverse Hispanic subgroups would be desirable. Approaches to promoting comparability could include, for example, additional standardization of methods for appropriate translation and cultural adaptation of survey instruments and/or expansion of asthma-related surveys in Puerto Rico. There is a current lack of information regarding Hispanic subgroups in national and state data sets, such as data on hospitalization and emergency department use. Efforts need to be made to improve the recording of Hispanic ethnicity in medical records. If such data were available, it would facilitate inclusion of information about Hispanic subgroups in asthma-related national reports, such as the National Healthcare Disparities Report.62
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our analysis of the 1997 to 2001 NHIS shows that grouping Hispanic individuals together in descriptions of asthma morbidity and risk factors conceals appreciable differences among Hispanic subgroups. In particular, greater attention should be given to understanding the burden of asthma among Puerto Rican individuals, developing strategies to ameliorate this burden, and elucidating the differential impact of acculturation on Hispanic asthma. Considering US Hispanic/Latino individuals as a homogeneous group with respect to asthma and other diseases can obscure the elucidation of disease prevention mechanisms and the evaluation of effective medical treatment and public health intervention strategies.
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ACKNOWLEDGMENTS |
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This work was conducted while M.L. was a Mentored Clinical Scientist sponsored by the Agency for Healthcare Research and Quality (grant K08 HS00008). The Ambulatory Pediatric Association Special Projects Program also provided initial support for this study, with funding from the Agency for Health Care Policy and Research and the Health Resources and Services Administration.
We thank Dr Neal Halfon for his assistance in identifying sources of funding for the initial phase of this work and Marian Branch, Linda Escalante, and Louis Ramírez for their editorial and administrative assistance. M.L. thanks her husband, Richard Greenberg, and their daughter, Serena Michelle Lara-Greenberg, for their unwavering support of this and other projects. This article is dedicated to all Hispanic children with asthma and their families.
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FOOTNOTES |
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Accepted Mar 23, 2005.
Address correspondence to Marielena Lara, MD, MPH, RAND Health, 1776 Main St, Santa Monica, CA 90407. E-mail: lara{at}rand.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
|---|
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
- Wissow LS, Gittelsohn AM, Szklo M, Starfield B, Mussman M. Poverty, race, and hospitalization for childhood asthma.
Am J Public Health. 1988;78
:777
–782
[Abstract/Free Full Text] - Wood PR, Hidalgo HA, Prihoda TJ, Kromer ME. Hispanic children with asthma: morbidity.
Pediatrics. 1993;91
:62
–69
[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] - Crain EF, Weiss KB, Bijur PE, et al. An estimate of the prevalence of asthma and wheezing among inner-city children.
Pediatrics. 1994;94
:356
–362
[Abstract/Free Full Text] - Miller JE. The effects of race/ethnicity and income on early childhood asthma prevalence and health care use.
Am J Public Health. 2000;90
:428
–430
[Abstract/Free Full Text] - Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality.
Pediatrics. 2002;110
:315
–322
[Abstract/Free Full Text] - 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] - 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]
- Gerstman BB, Bosco LA, Tomita DK. Trends in the prevalence of asthma hospitalization in the 5- to 14-year-old Michigan Medicaid population, 1980 to 1986. J Allergy Clin Immunol. 1993;91 :838 –843[CrossRef][Web of Science][Medline]
- 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] - 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] - 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] - Burchard EG, Avila PC, Nazario S, et al. Lower bronchodilator responsiveness in Puerto Rican than in Mexican subjects with asthma.
Am J Respir Crit Care Med. 2004;169
:386
–392
[Abstract/Free Full Text] - Freeman NC, Schneider D, McGarvey P. Household exposure factors, asthma, and school absenteeism in a predominantly Hispanic community. J Expo Anal Environ Epidemiol. 2003;13 :169 –176[CrossRef][Web of Science][Medline]
- Morales LS, Lara M, Kington RS, Valdez RO, Escarce JJ. Socioeconomic, cultural, and behavioral factors affecting Hispanic health outcomes. J Health Care Poor Underserved. 2002;13 :477 –503[CrossRef][Web of Science][Medline]
- Flores G, Bauchner H, Feinstein AR, Nguyen US. The impact of ethnicity, family income, and parental education on children's health and use of health services.
Am J Public Health. 1999;89
:1066
–1071
[Abstract/Free Full Text] - Flores G, Fuentes-Afflick E, Barbot O, et al. The health of Latino children: urgent priorities, unanswered questions, and a research agenda.
JAMA. 2002;288
:82
–90
[Abstract/Free Full Text] - Mendoza FS, Ventura SJ, Valdez RB, et al. Selected measures of health status for Mexican-American, mainland Puerto Rican, and Cuban-American children.
JAMA. 1991;265
:227
–232
[Abstract/Free Full Text] - Fuentes-Afflick E, Lurie P. Low birth weight and Latino ethnicity: examining the epidemiologic paradox.
Arch Pediatr Adolesc Med. 1997;151
:665
–674
[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] - 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]
- Orengo JC, Loyo NI, Serrano RA, Mercado HE, Horta H. Prevalence of respiratory and allergic problems among school-aged children in the Air Basin. Presented at the Cataño Workshop; April 1996; San Juan, Puerto Rico
- Perez-Perdomo R, Perez-Cardona C, Disdier-Flores O, Cintron Y. Prevalence and correlates of asthma in the Puerto Rican population: Behavioral Risk Factor Surveillance System, 2000. J Asthma. 2003;40 :465 –474[CrossRef][Web of Science][Medline]
- Arif AA, Borders TF, Patterson PJ, Rohrer JE, Xu KT. Prevalence and correlates of paediatric asthma and wheezing in a largely rural USA population. J Paediatr Child Health. 2004;40 :189 –194[CrossRef][Web of Science][Medline]
- Mannino DM, Homa DM, Akinbami LJ, et al. Surveillance for asthma: United States, 1980–1999. MMWR Surveill Summ. 2002;51(1) :1 –13
- Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life.
N Engl J Med. 1995;332
:133
–138
[Abstract/Free Full Text] - Research Triangle Institute. SUDAAN. Research Triangle Park, NC: Research Triangle Institute; 2003
- 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] - Infante-Rivard C, Gautrin D, Malo JL, Suissa S. Maternal smoking and childhood asthma.
Am J Epidemiol. 1999;150
:528
–531
[Abstract/Free Full Text] - Agabiti N, Mallone S, Forastiere F, et al. The impact of parental smoking on asthma and wheezing. Epidemiology. 1999;10 :692 –698[CrossRef][Web of Science][Medline]
- Gennuso J, Epstein LH, Paluch RA, Cerny F. The relationship between asthma and obesity in urban minority children and adolescents.
Arch Pediatr Adolesc Med. 1998;152
:1197
–1200
[Abstract/Free Full Text] - Epstein LH, Wu YW, Paluch RA, Cerny FJ, Dorn JP. Asthma and maternal body mass index are related to pediatric body mass index and obesity: results from the Third National Health and Nutrition Examination Survey. Obes Res. 2000;8 :575 –581[Web of Science][Medline]
- von Mutius E, Schwartz J, Neas LM, Dockery D, Weiss ST. Relation of body mass index to asthma and atopy in children: the National Health and Nutrition Examination Study III.
Thorax. 2001;56
:835
–838
[Abstract/Free Full Text] - Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care.
Chest. 1998;114
:1008
–1015
[Abstract/Free Full Text] - Centers for Disease Control and Prevention. Epi Info 2002. Atlanta, GA: Centers for Disease Control and Prevention; 2002
- World Health Organization. WHO Technical Series: Physical Status: The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee. Geneva, Switzerland: World Health Organization; 1995
- Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 11. 2002;(246 ):1 –190
- Michels KB, Greenland S, Rosner BA. Does body mass index adequately capture the relation of body composition and body size to health outcomes?
Am J Epidemiol. 1998;147
:167
–172
[Abstract/Free Full Text] - 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] - 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]
- 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]
- Klinnert MD, Price MR, Liu AH, Robinson JL. Unraveling the ecology of risks for early childhood asthma among ethnically diverse families in the Southwest.
Am J Public Health. 2002;92
:792
–798
[Abstract/Free Full Text] - Vitullo MW, Taylor AK. Latino adults' health insurance coverage: an examination of Mexican and Puerto Rican subgroup differences. J Health Care Poor Underserved. 2002;13 :504 –525[CrossRef][Web of Science][Medline]
- Pachter LM, Weller SC. Acculturation and compliance with medical therapy. Dev Behav Pediatr. 1993;14 :163 –168[Web of Science][Medline]
- Lara M, Morgenstern H, Duan N, Brook RH. Elevated asthma morbidity in Puerto Rican children: a review of possible risk and prognostic factors. West J Med. 1999;170 :75 –84[Web of Science][Medline]
- Strunk RC, Ford JG, Taggart V. Reducing disparities in asthma care: priorities for research: National Heart, Lung, and Blood Institute workshop report. J Allergy Clin Immunol. 2002;109 :229 –237[CrossRef][Medline]
- Brooks AM, Byrd RS, Weitzman M, Auinger P, McBride JT. Impact of low birth weight on early childhood asthma in the United States.
Arch Pediatr Adolesc Med. 2001;155
:401
–406
[Abstract/Free Full Text] - Becerra JE, Smith JC. Breastfeeding patterns in Puerto Rico.
Am J Public Health. 1990;80
:694
–697
[Abstract/Free Full Text] - Centers for Disease Control and Prevention. Infant health among Puerto Ricans: Puerto Rico and U.S. mainland, 1989–2000. MMWR Morb Mortal Wkly Rep. 2003;52 :1012 –1016[Medline]
- Miller JE, Gaboda D, Davis D. Early childhood chronic illness: comparability of maternal reports and medical records. Vital Health Stat 2. 2001;131 :1 –10
- Findley S, Lawler K, Bindra M, et al. Elevated asthma and indoor environmental exposures among Puerto Rican children of East Harlem. J Asthma. 2003;40 :557 –569[CrossRef][Web of Science][Medline]
- Celedon JC, Sredl D, Weiss ST, et al. Ethnicity and skin test reactivity to aeroallergens among asthmatic children in Connecticut.
Chest. 2004;125
:85
–92
[Abstract/Free Full Text] - Manson A. Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Med Care. 1988;26 :1119 –1127[CrossRef][Web of Science][Medline]
- Halterman JS, Aligne CA, Auinger P, McBride JT, Szilagyi PG. Inadequate therapy for asthma among children in the United States.
Pediatrics. 2000;105
:272
–276
[Abstract/Free Full Text] - Weinick RM, Krauss NA. Racial/ethnic differences in children's access to care.
Am J Public Health. 2000;90
:1771
–1774
[Abstract/Free Full Text] - Ortega AN, Gergen PJ, Paltiel AD, et al. Impact of site of care, race, and Hispanic ethnicity on medication use for childhood asthma. Pediatrics. 2002;109(1) . Available at: www.pediatrics.org/cgi/content/full/109/1/e1
- Diaz T, Sturm T, Matte T, et al. Medication use among children with asthma in East Harlem.
Pediatrics. 2000;105
:1188
–1193
[Abstract/Free Full Text] - Pachter LM, Cloutier MM, Bernstein BA. Ethnomedical (folk) remedies for childhood asthma in a mainland Puerto Rican community.
Arch Pediatr Adolesc Med. 1995;149
:982
–988
[Abstract/Free Full Text] - Zayas LE, Jaen CR, Kane M. Exploring lay definitions of asthma and interpersonal barriers to care in a predominantly Puerto Rican, inner-city community. J Asthma. 1999;36 :527 –537[Web of Science][Medline]
- Pachter LM, Weller SC, Baer RD, et al. Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans. J Asthma. 2002;39 :119 –134[CrossRef][Web of Science][Medline]
- Lieu TA, Finkelstein JA, Lozano P, et al. Cultural competence policies and other predictors of asthma care quality for Medicaid-insured children. Pediatrics. 2004;114(1) . Available at: www.pediatrics.org/cgi/content/full/114/1/e102
- Institute of Medicine, Committee on Guidance for Designing a National Healthcare Disparities Report. Guidance for the National Healthcare Disparities Report. Washington, DC: National Academy Press; 2002
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