Impact of asthma intervention in two elementary school-based health centers in the Bronx, New York City

School-based health centers as an approach to address health disparities among rural youth: A study protocol for a multilevel research framework

School-Based Health Centers (SBHCs) are important healthcare providers for children in medically underserved communities. While most existing research on SBHCs has focused on urban environments, this study protocol proposes a mixed-methods, multi-level research framework to evaluate the role of SBHCs in addressing health disparities among underserved children and adolescents in rural communities. The study area includes four high-poverty rural counties in New York State served by Bassett Healthcare Network that permits a comparison of school districts with SBHCs to those without SBHCs, all served by providers within the Bassett Healthcare Network. We employ a human ecological framework that integrates the micro layer of individuals and families, the meso layer of school districts and community institutions, and the macro layer of local and state policies. Our research framework first identifies the socioecological health risk factors, and then proposes innovative strategies to investigate how SBHCs impact them. We propose evaluating the impact of SBHCs on the individual (micro) level of child healthcare utilization using patient records data. At the meso level, we propose to investigate how School-SBHCs partnership may facilitate greater cross-agency collaboration and broader structural and social determinist of health to address health disparities. At the macro level, we propose to assess the impact of SBHCs and cross-agency collaboration on outcomes associated with a culture of community health. This study protocol will enable researchers to assess how SBHCs reduce rural health disparities, and provide evidence for organizational and public policy change.

Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia

OBJECTIVES

We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP).

METHODS

We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year.

RESULTS

We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC.

CONCLUSION

Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

Improving teacher comfort and self-efficacy in asthma management

Background: Asthma is common among urban school-age children. Though teachers should be prepared to assist children during an asthma attack, studies show they lack self-efficacy in managing asthma.Objective: To assess feasibility of implementing an asthma workshop for elementary school teachers, describe themes of questions raised, and determine workshop's impact on teachers' comfort and self-efficacy in asthma management.Methods: We developed and implemented an asthma workshop for teachers from four Bronx elementary schools (2012-2014). Teachers completed a questionnaire evaluating their comfort and self-efficacy in asthma management before and after the workshop. Questions asked during the sessions were recorded and analyzed for themes. Paired t-test and McNemar tests compared before/after scores.Results: 65 out of 70 teachers (92.9%) participated in the educational sessions. Teachers asked questions about school policy for inhalers, medication administration guidelines, and physical activity and asthma. 64/65 (98.5%) teachers completed pre/post surveys (mean age 39.7 years; mean years at the school 8.0). Post-intervention, more teachers reported knowing how to manage an asthma attack (93.8% vs. 64.1%, p < .0001); and felt comfortable assessing (50.8% vs. 30.8%, p = 0.019) and handling an asthma attack (52.3% vs. 33.8%, p = .023). The overall mean self-efficacy score increased post-intervention (43.0 vs. 38.1, p < .0001), as did 8/12 individual self-efficacy items. Post-workshop, 95.3% of teachers agreed that teacher in-service asthma education should be done annually.Conclusions: An asthma workshop was successfully implemented in the school setting and improved teacher comfort and self-efficacy in managing asthma. Annual training may improve teachers' confidence in assisting students with asthma.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Pediatric asthma hospitalizations among urban minority children and the continuity of primary care

OBJECTIVE

To examine the effect of ambulatory health care processes on asthma hospitalizations.

METHODS

A retrospective cohort study using electronic health records was completed. Patients aged 2-18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations.

RESULTS

5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09-1.78).

CONCLUSIONS

In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.

The Role of School Health Services in Addressing the Needs of Students With Chronic Health Conditions

Children and adolescents in the United States spend many hours in school. Students with chronic health conditions (CHCs) may face lower academic achievement, increased disability, fewer job opportunities, and limited community interactions as they enter adulthood. School health services provide safe and effective management of CHCs, often for students with limited access to health care. A systematic review to assess the role of school health services in addressing CHCs among students in Grades K-12 was completed using primary, peer-reviewed literature published from 2000 to 2015, on selected conditions: asthma, food allergies, diabetes, seizure disorders, and poor oral health. Thirty-nine articles met the inclusion criteria and results were synthesized; however, 38 were on asthma. Direct access to school nursing and other health services, as well as disease-specific education, improved health and academic outcomes among students with CHCs. Future research needs to include standardized definitions and data collection methods for students with CHCs.

Opening School-Based Health Centers in a Rural Setting: Effects on Emergency Department Use

BACKGROUND

Previous studies of urban school-based health centers (SBHCs) have shown that SBHCs decrease emergency department (ED) utilization. This study seeks to evaluate the effect of SBHCs on ED utilization in a rural setting.

METHODS

This retrospective, controlled, quasi-experimental study used an ED patient data set from the Bassett Healthcare Network in rural New York to compare ED visits between school-aged children from 12 SBHC schools before and after the SBHC opening. Time series analysis was used to determine trends in SBHC schools and 2 control schools without SBHCs over the 18-year study period.

RESULTS

ED visit incidence densities for all 12 school districts combined showed a significant increase in ED visits post-SBHC (Rate ratio (RR) = 1.15; p < .0001). This increase may, in part, be explained by the upward trend of ED visits in the region, as seen in the small, but significant, positive slope (RR = 0.0033, p < .0001) for control schools. There was variation in the change in incidence density post-SBHC among school districts, with increases in 78% of schools.

CONCLUSIONS

The opening of SBHCs in rural settings results in a slight, but significant, increase in ED use, which is contrary to previous cross-sectional studies in urban settings.

School-based health centers in an era of health care reform: building on history

School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.

The health care home model: primary health care meeting public health goals

In November 2010, the American Public Health Association endorsed the health care home model as an important way that primary care may contribute to meeting the public health goals of increasing access to care, reducing health disparities, and better integrating health care with public health systems. Here we summarize the elements of the health care home (also called the medical home) model, evidence for its clinical and public health efficacy, and its place within the context of health care reform legislation. The model also has limitations, especially with regard to its degree of involvement with the communities in which care is delivered. Several actions could be undertaken to further develop, implement, and sustain the health care home.

Asthma outcomes: healthcare utilization and costs

BACKGROUND

Measures of healthcare utilization and indirect impact of asthma morbidity are used to assess clinical interventions and estimate cost.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to propose standardized measurement, collection, analysis, and reporting of healthcare utilization and cost outcomes in future asthma studies.

METHODS

We used comprehensive literature reviews and expert opinion to compile a list of asthma healthcare utilization outcomes that we classified as core (required in future studies), supplemental (used according to study aims and standardized), and emerging (requiring validation and standardization). We also have identified methodology to assign cost to these outcomes. This work was discussed at an National Institutes of Health-organized workshop in March 2010 and finalized in September 2011.

RESULTS

We identified 3 ways to promote comparability across clinical trials for measures of healthcare utilization, resource use, and cost: (1) specify the study perspective (patient, clinician, payer, and society); (2) standardize the measurement period (ideally 12 months); and (3) use standard units to measure healthcare utilization and other asthma-related events.

CONCLUSIONS

Large clinical trials and observational studies should collect and report detailed information on healthcare utilization, intervention resources, and indirect impact of asthma, so that costs can be calculated and cost-effectiveness analyses can be conducted across several studies. Additional research is needed to develop standard, validated survey instruments for collection of provider-reported and participant-reported data regarding asthma-related health care.

Learning social medicine in the Bronx: an orientation for primary care residents

BACKGROUND

Primary care educators face the challenge of teaching the social context of health and disease to clinicians.

DESCRIPTION

Since 1975, the Residency Program in Social Medicine has trained clinicians to practice in urban underserved communities. During Orientation Month, 1st-year residents are relieved of inpatient duties and participate in learning activities addressing social and cultural aspects of health. Learning objectives include understanding patients' social context, their community, and the role of physicians as professionals. Recent innovations include incorporating an overall theme, weekly case studies, "triple jump" exercises, community mapping projects, patient-led community tours, and theme-specific visits to community institutions (e.g., prisons).

EVALUATION

Residents complete weekly formative evaluations, a summative evaluation, and narrative reflections. Faculty complete an evaluative questionnaire.

CONCLUSIONS

Orientation is a highly rated and valued part of our curriculum. Its success derives from ongoing curricular innovation and evolution, a departmental commitment to social medicine, and positive community response to our learners' interest and energy.

Educational and behavioral interventions for asthma: who achieves which outcomes? A systematic review

OBJECTIVES

Randomized clinical trial (RCT) data reviewed for outcomes and processes associated with asthma educational and behavioral interventions provided by different types of health professionals.

METHODS

Cochrane Collaboration, MEDLINE, PUBMED, Google Scholar search from 1998 to 2009 identified 1650 articles regarding asthma educational and behavioral interventions resulting in 249 potential studies and following assessment produced a final sample of 50 RCTs.

RESULTS

Approaches, intended outcomes, and program providers vary greatly. No rationale provided in study reports for the selection of specific outcomes, program providers, or program components. Health care utilization and symptom control have been the most common outcomes assessed. Specific providers favor particular teaching approaches. Multidisciplinary teams have been the most frequent providers of asthma interventions. Physician-led interventions were most successful for outcomes related to the use of health care. Multidisciplinary teams were best in achieving symptom reduction and quality of life. Lay persons were best in achieving self-management/self-efficacy outcomes. Components most frequently employed in successful programs are skills to improve patient-clinician communication and education to enhance patient self-management. Fifty percent of interventions achieved reduction in the use of health care and one-third in symptom control. A combination approach including self-management and patient-clinician communication involving multidisciplinary team members may have the greatest effect on most outcomes.

CONCLUSIONS

The extent to which and how different providers achieve asthma outcomes through educational and behavioral interventions is emerging from recent studies. Health care use and symptom control are evolving as the gold standard for intervention outcomes. Development of self-management and clinician-patient communication skills are program components associated with success across outcomes and providers.

The impact of school-based health centers on the health outcomes of middle school and high school students

OBJECTIVES

We studied the direct and indirect effects of school-based health centers (SBHCs) on the health and health behaviors of middle and high school students.

METHODS

We used a prospective cohort design to measure health outcomes annually over 2 consecutive years by student self-report. Cohorts of middle school and high school students were recruited from matched schools with and without SBHCs. Data were obtained from 744 students in both year 1 and year 2 of the study. We used 2-level hierarchical linear models to estimate the effects of the presence of SBHCs at the school level and of SBHC use at the student level.

RESULTS

At year 2, users of SBHCs experienced greater satisfaction with their health, more physical activity, and greater consumption of healthy food than did nonusers of SBHCs.

CONCLUSIONS

Students who used SBHCs were more satisfied with their health and engaged in a greater number of health-promoting behaviors than did students who did not use SBHCs. These findings indicate that SBHCs are achieving their goal of promoting children's health.

Maternal mental health and childhood asthma among Puerto Rican youth: the role of prenatal smoking

RATIONALE

Childhood asthma is a major public health problem, with mainland and island Puerto Rican children having the highest asthma rates of any ethnic group in the United States.

OBJECTIVES

To examine the relationship between maternal mental health problems, prenatal smoking, and risk of asthma among children in Puerto Rico and the Bronx, New York.

METHODS

A cross-sectional community-based study was conducted in the South Bronx in New York City and the San Juan Standard Metropolitan Area in Puerto Rico. Participants were Puerto Rican children 5 to 13 years of age and their adult caretakers with probability samples of children 5 to 13 years of age and their caregivers drawn at two sites: the South Bronx in New York City (n = 1,135) and San Juan and Caguas, Puerto Rico (n = 1,351).

MEASUREMENTS

Self-reported maternal mental health, prenatal smoking, and rates of childhood asthma. Results. Maternal mental health problems were associated with significantly higher levels of prenatal smoking, compared with that among women without mental health problems (p < 0.0001). Both maternal mental health problems and prenatal smoking appear to make a contribution to increased odds of asthma among youth. After adjusting for prenatal smoking, the relationship between maternal mental health problems and childhood asthma was no longer statistically significant.

CONCLUSIONS

Previous research suggests children of Puerto Rican descent are especially vulnerable to asthma. Our results suggest that maternal mental health problems and prenatal smoking are both associated with increased odds of asthma among Puerto Rican youth and that prenatal smoking may partly explain the observed relationship between maternal psychopathology and childhood asthma. Future longitudinal and geographically diverse epidemiological studies may help to identify the role of both maternal mental health problems and prenatal smoking in the health disparities in childhood asthma.

Pursuing perfection: an asthma quality improvement initiative in school-based health centers with community partners

This article describes an innovative asthma quality improvement initiative conducted in school-based health centers (SBHCs) with collaboration among multiple community partners including the children's hospital, a federally qualified health center, the health department, the public school, and parents of children with asthma. The aim was to improve the health of children with asthma in these schools, as measured by minimal asthma-related activity restriction and reduction in asthma-related emergency department (ED) visits. Process measures tracked included the percent of children with (1) asthma severity classified, (2) persistent asthma with controller medication prescribed, and (3) written care plans. Data supported a statistically significant decreasing trend for the percent of SBHC children reporting activity restriction due to asthma. In addition, trend analysis demonstrated a statistically significant difference in ED visits for asthma in the SBHC group compared with a non-SBHC group. Improvements were demonstrated for all process measures. Factors contributing to success included emphasis on community engagement, transparency in sharing ideas and results, benefits outweighing human resource costs of participating, readily available data to drive improvement, and the use of multiple intervention strategies.

School-based asthma programs

Asthma is prevalent in school-age children and contributes to school absenteeism and limitation of activity. There is a sizable literature on school-based interventions for asthma that attempt to identify children with asthma and improve outcomes. The purpose of this review is to describe and discuss limitations of screening tools and school-based asthma interventions. Identification of children with asthma may be appropriate in schools located in districts with a high prevalence of children experiencing significant morbidity and a high prevalence of undiagnosed asthma, provided there is access to high-quality asthma care. We review strategies for improving access to care, for teaching self-management skills in schools, and for improving school personnel management skills. Although studies indicate that school-based programs have the potential to improve outcomes, competing priorities in the educational system present challenges to their implementation and emphasize the need for practical, targeted, and cost-effective strategies.

Childhood asthma and extreme values of body mass index: the Harlem Children's Zone Asthma Initiative

To examine the association between body mass index (BMI) percentile and asthma in children 2-11 years of age, we performed a cross-sectional analysis of 853 Black and Hispanic children from a community-based sample of 2- to 11-year olds with measured heights and weights screened for asthma by the Harlem Children's Zone Asthma Initiative. Current asthma was defined as parent/guardian-reported diagnosis of asthma and asthma-related symptoms or emergency care in the previous 12 months. Among girls, asthma prevalence increased approximately linearly with increasing body mass index (BMI) percentile, from a low of 12.0% among underweight girls (BMI 95th percentile). After adjusting for age, race/ethnicity, and household smoking, among girls, having asthma was associated with being at risk for overweight (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.4-5.0) and being overweight (OR, 2.1; 95% CI, 1.2-3.8) compared to normal weight; among boys, having asthma was associated both with overweight (OR, 2.4; 95% CI, 1.4-4.3) and with underweight (OR, 2.9; 95% CI, 1.1-7.7). Large, prospective studies that include very young children are needed to further explore the observed association between underweight and asthma among boys. Early interventions that concomitantly address asthma and weight gain are needed among pre-school and school-aged children.