Development and validation of a brief pediatric screen for asthma and allergies among children

A Risk Stratification Algorithm for Asthma Identification and Prioritization in a Low-Income Urban School

BACKGROUND

Asthma can interfere with school attendance and engagement. School health programs are central to asthma management. Case identification is limited by reliance on parent-completed forms, which are often missing. This project tested a low-burden screening algorithm to stratify students based on priority for nurse outreach at 2 large, urban schools with high asthma prevalence.

METHODS

Students in grades 1-8 completed a 4-item asthma screener. Two-stage stratification incorporated screener responses, school nurse records, and absenteeism. Students were assigned low, medium, or high priority for follow up. Asthma prevalence in the high priority group was calculated for substantiated asthma. Whether stratification was more likely than chance to identify new cases of asthma in the high-priority group was evaluated using chi-square tests.

RESULTS

Of 1397 students, 69.7% were screened. Secondary stratification decreased the number of students in the high and medium priority groups. New asthma cases were identified in 46.4% of high-priority families reached for follow up. High-priority students were more likely to be identified as having asthma than chance alone (p < .001).

CONCLUSIONS

A low-burden screening algorithm appropriately placed students with asthma in the high priority group. This approach may allow efficient, targeted follow up of the highest need students in high prevalence populations.

An Examination of the Association of Multiple Acculturation Measures with Asthma Status Among Elementary School Students in El Paso, Texas

Some researchers posit that the lower prevalence of asthma among those of Mexican descent may result from an under-diagnosis and recommend a critical appraisal of factors related to race/ethnicity, like acculturation, and its influence on asthma status. Survey data were analyzed using multinomial logistic regression to examine the association of child's asthma status (no wheezing/no asthma symptoms, possible undiagnosed and diagnosed asthma) with measures of acculturation among Hispanic students (n = 1095). In this population, the prevalence of diagnosed asthma (15%) was higher than both national (7.6%) and state (6.8%) averages for Hispanic children in 2012. While bivariate analyses showed significant associations for asthma status and measures of acculturation, multivariate analyses did not. There is an underestimated burden of illness among Hispanic children in El Paso County. More research on the suitability of acculturation constructs is needed to delineate what they actually measure and how acculturation influences asthma status.

Agreement between asthma questionnaire and health care register data

PURPOSE

Risk factors and consequences of asthma can be studied by using validated questionnaires. The overall objective of this study was to assess the agreement of parental-reported asthma-related questions regarding their children against Swedish health care registers.

METHODS

We linked a population-based twin cohort of 27 055 children aged 9 to 12 years to the Swedish Prescribed Drug Register, National Patient Register, and the primary care register. Parent-reported asthma was obtained from questionnaires, and diagnoses and medication were retrieved from the registers. For the agreement between the questionnaire and the registers, Cohen's kappa was estimated.

RESULTS

The kappa of the "reported ever asthma" against a "register-based ever asthma" was 0.69 and 0.57 between the parental-"reported doctor's diagnosis" and "register-based doctor's diagnosis." The highest agreement between "reported current asthma" and "register-based current asthma" with at least 1 dispensed medication or a diagnosis applied to different time windows was seen for an 18-month window (kappa = 0.70).

CONCLUSIONS

We found that parent-reported asthma-related questions showed on average good agreement with the Swedish health care registers. This implies that in-depth questionnaires with rich information on phenotypes are suitable proxies for asthma in general and can be used for health care research purposes.

Application of an Asthma Screening Questionnaire in Children with Sickle Cell Disease

Objective: Asthma in sickle cell disease (SCD) patients is associated with elevated morbidity and mortality. Early detection and initiation of treatment may therefore lead to improved outcome. Utility of an asthma screening questionnaire to identify obstructive airway disease and physician diagnosed asthma in children with SCD at an outpatient setting as an effective, easy-to-administer screening tool has not previously been evaluated in this population. Methods: A previously validated asthma screening questionnaire and spirometry were prospectively administered to 41 SCD children at a routine clinic visit. Results: Prevalence of obstructive airway was 51.2% (n = 21) and physician diagnosis of asthma 33.3% (n = 13). Sensitivity (40%) and specificity (75%) of the questionnaire was poor in detecting obstructive airway disease, but sensitivity (77%), specificity (100%), positive predictive value (100%), and negative predictive value (90%) were high in detecting physician diagnosis of asthma. Conclusion: An asthma screening questionnaire could be a useful tool in identifying at-risk SCD children who may benefit from further management.

Asthma and physical activity in multiracial girls from three US sites

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Caregiver expectations of clinicians during the asthma diagnostic process in young children: thematic analysis of focus groups

OBJECTIVE

Asthma is difficult to diagnose in young children, and the subjective experience of caregivers varies. Clinicians' ability to meet caregiver expectations during the diagnostic process improves the caregiver-clinician relationship, and effectiveness of disease management strategies.

METHODS

We performed thematic analysis of seven focus groups (FGs) with 38 caregivers of children 1-6 years old diagnosed with asthma in the preceding 12 months. Caregivers were classified as satisfied or dissatisfied with clinicians during the asthma diagnostic process. Differential themes in these two groups identified caregiver expectations that determined satisfaction with the diagnostic process.

RESULTS

Caregiver expectations during the asthma diagnostic process included (1) provision of a diagnostic strategy, (2) acknowledgment of caregiver advocacy, (3) addressing caregiver's beliefs about treatment with asthma medications before a diagnosis was confirmed, and (4) discussing asthma specialist involvement in the diagnosis. Higher perceived severity of a child's illness made caregiver expectations more difficult to meet.

CONCLUSIONS

We conclude that clinicians considering an asthma diagnosis in young children must include a diagnostic strategy that is congruent with the caregiver's beliefs about the underlying illness, use of medication, and asthma specialist involvement. Perceived illness severity must also be accounted for when designing a diagnostic strategy.

Pulmonary function in children after surgical and percutaneous closure of atrial septal defect

This study aimed to study differences in lung function after surgical and percutaneous atrial septal defect (ASD) closure. Several studies have demonstrated abnormalities of pulmonary function in adults and children with ASD. These abnormalities persist even a few years after correction. This study compared pulmonary function between patients who underwent ASD closure by surgery and those who had closure by device. This is the ideal pediatric population for studying changes in lung function caused by cardiopulmonary bypass or sternotomy. The 46 patients in this study were treated by percutaneous closure (group 1) or surgical closure (group 2) of ASD and then scheduled for pulmonary function testing an average of 5.8 years after ASD closure. The mean values of functional residual capacity, total lung capacity, and residual volume did not differ between the two groups. The surgical group showed a significant decrease in expiratory reserve volume (p < 0.04) and forced vital capacity (p < 0.03). Expiratory flow at 25, 50, and 75% of forced vital capacity did not differ between the two groups but was on the lower limit of normal in both groups. Percutaneous closure of ASD can minimize the side effects of surgical closure on lung function. Longitudinal lung function follow-up assessment after cardiac surgery is warranted to detect and measure restrictive abnormalities in this type of congenital heart disease and others.

Stress and the city: housing stressors are associated with respiratory health among low socioeconomic status Chicago children

Asthma disproportionately affects non-whites in urban areas and those of low socioeconomic status, yet asthma's social patterning is not well-explained by known risk factors. We hypothesized that disadvantaged urban populations experience acute and chronic housing stressors which produce psychological stress and impact health through biological and behavioral pathways. We examined eight outcomes: six child respiratory outcomes as well as parent and child general health, using data from 682 low-income, Chicago parents of diagnosed and undiagnosed asthmatic children. We created a continuous exposure, representing material, social and emotional dimensions of housing stressors, weighted by their parent-reported difficulty. We compared the 75th to the 25th quartile of exposure in adjusted binomial and negative binomial regression models. Higher risks and rates of poor health were associated with higher housing stressors for six of eight outcomes. The risk difference (RD) for poor/fair general health was larger for children [RD = 6.28 (95% CI 1.22, 11.35)] than for parents [RD = 3.88 (95% CI -1.87, 9.63)]. The incidence rate difference (IRD) for exercise intolerance was nearly one extra day per 2 weeks for the higher exposure group [IRD = 0.88 (95% CI 0.41, 1.35)]; nearly one-third extra day per 2 weeks for waking at night [IRD = 0.32 (95% CI 0.01, 0.63)]; and nearly one-third extra day per 6 months for unplanned medical visits [IRD = 0.30 (95% CI 0.059, 0.54)]. Results contribute to the conceptualization of urban stress as a "social pollutant" and to the hypothesized role of stress in health disparities. Interventions to improve asthma outcomes must address individuals' reactions to stress while we seek structural solutions to residential stressors and health inequities.

The state of pediatric asthma in Chicago's Humboldt Park: a community-based study in two local elementary schools

BACKGROUND

Pediatric asthma is a serious public health problem in Chicago and has been designated a high priority concern by residents of Chicago's Humboldt Park, a diverse community area with a large number of Puerto Rican, African American, and Mexican American families.

METHODS

In May 2009, following the principles of community-based participatory research, a cross-sectional asthma screening survey was administered to adult caregivers of children attending two Humboldt Park elementary schools. Data were analyzed to determine the prevalence of diagnosed and probable asthma as well as the degree of asthma control among affected children; associations between asthma outcomes and mutable triggers were evaluated.

RESULTS

Surveys from 494 children were evaluated. Physician-diagnosed asthma was reported for 24.9% of children and probable asthma identified in an additional 16.2% of children. Asthma was poorly or moderately controlled in 60.0% of diagnosed children. Smoking occurred inside 25.0% of households and 75.0% of caregivers reported idling of vehicles in their community. Report of general stress among caregivers, stress due to community crime, and/or an inability to cope with everyday life were significantly and positively associated with poor asthma morbidity and control among affected children.

CONCLUSIONS

Despite high prevalence rates and poor asthma morbidity and control in Humboldt Park, the association of these measures with mutable variables is promising. A community-based asthma intervention to address the issues identified in this study is needed to affect positive change.

The association between community crime and childhood asthma prevalence in Chicago

BACKGROUND

Little attention has been given to exposure to crime as a possible socioenvironmental contributor to variability in urban childhood asthma prevalence.

OBJECTIVE

To determine the association of violent crime, property crime, and drug abuse violations with childhood asthma prevalence in Chicago.

METHODS

In 2003-2005, the Chicago Initiative to Raise Asthma Health Equity conducted an asthma screening survey of children in grades K to 8 attending Chicago public and Catholic schools. Crime data were obtained from the Chicago Police Department. In addition to simple regression analysis, multilevel logistic regression analysis was performed to estimate the effect of criminal activity on neighborhood asthma variance.

RESULTS

Of the surveys returned, 45,371 (93%) were geocoded into 247 neighborhoods. Neighborhoods were divided into quartile groups by mean asthma prevalence (9%, 12%, 17%, and 22%). Criminal activity (annual incidence per 100,000 people) was significantly higher (P < .001) in neighborhoods with a high asthma prevalence, especially drug abuse violations, which increased more than 6-fold (461 vs 2,921), and violent crimes, which increased more than 3-fold (448 vs 1,566). After adjusting for community race/ethnicity, only violent crime continued to be significantly associated with the neighborhood asthma prevalence (odds ratio, 1.27; 95% confidence interval, 1.04-1.55, P < .05). When considered alongside sociodemographic and individual characteristics, violence continued to contribute significantly (P < .05), explaining 15% of neighborhood variation in childhood asthma.

CONCLUSIONS

Evidence suggests an association between violent crime and childhood asthma prevalence in Chicago. A deeper understanding of the mechanisms that underlie this association may lend insight into potential interventions to address urban asthma.

Parent perceptions of neighborhood stressors are associated with general health and child respiratory health among low-income, urban families

BACKGROUND

This cross-sectional study examines parents' perceptions of their neighborhoods and general and respiratory health among low-income Chicago families. Asthma disproportionately affects nonwhite, urban, and low socioeconomic status (SES) populations, but Chicago's burden, and the national epidemic, are not well explained by known risk factors. Urban dwellers experience acute and chronic stressors that produce psychological distress and are hypothesized to impact health through biological and behavioral pathways. Identifying factors that covary with lower SES and minority-group status-e.g., stress-is important for understanding asthma's social patterning.

METHODS

We used survey data from 319 parents of children 5-13 years with asthma/respiratory problems and principal components analysis to create exposure variables representing parents' perceptions of two aspects of neighborhoods: collective efficacy ("CE") and physical/social order ("order"). Adjusted binomial regression models estimated risk differences (RDs) and 95% confidence intervals (CIs) for eight binary outcomes.

RESULTS

Magnitude was generally as expected, i.e., RD for low- versus high- (most favorable) exposure groups (RD(low v. high)) was larger than for the middle versus high contrast (RD(mid v. high)). "Parent general health" was strongly associated with "CE" (RD(low v. high) = 20.8 [95% CI: 7.8, 33.9]) and "order" (RD(mid v. high) = 11.4 [95% CI: 2.1, 20.7]), unlike "child general health," which had nearly null associations. Among respiratory outcomes, only "waking at night" was strongly associated with "CE" (RD(low v. high) = 16.7 [95% CI: 2.8, 30.6]) and "order" (RD(low v. high) = 22.2 [95% CI: 8.6, 35.8]). "Exercise intolerance" (RD(low v. high) = 15.8 [95% CI: 2.1, 29.5]) and "controllability" (RD(mid v. high) = 12.0 [95% CI: 1.8, 22.3]) were moderately associated with "order" but not with "CE," whereas "school absences," "rescue medication use," and "unplanned visits" had nearly null associations with both exposures.

CONCLUSIONS

More negative perceptions tended to be associated with higher risk of undesirable outcomes, adding to evidence that the social environment contributes to health and supporting research on stress' health impact among disadvantaged populations. Interventions must address not only traditional "environmental" factors, but also individuals' reactions to stress and attempt to mitigate effects of stressors while structural solutions to health inequities are sought.

The association of allergic symptoms with sensitization to inhalant allergens in childhood

Although it is generally agreed that sensitization is an important risk factor for allergic diseases, the extent to which sensitization accounts for allergic symptoms in children is controversial. As part of the Aalst Allergy Study, this cross-sectional study investigated the prevalence of allergic symptoms and their association with sensitization in an unselected population of Flemish children aged 3.4-14.8 yr. Skin prick testing with the most common aeroallergens was performed and allergic symptoms were documented by a parental questionnaire. In the children older than 6 yr, a significant association of current wheezing, current dyspnea, airway hyperreactivity, rhinoconjunctivitis, and current eczema with sensitization was found, while in the pre-school children these associations were less pronounced. The association with sensitization was strongest for rhinoconjunctivitis and current respiratory symptoms - the association was less striking for children with current eczema. The impact of a positive family history of allergy on the association with sensitization was more important for eczema than for the other analyzed allergic symptoms. Persistent and late-onset wheezers were significantly more likely than non-wheezers and transient early wheezers to be associated with sensitization and a personal history of rhinoconjunctivitis. Late-onset wheezing was associated with a positive family history of allergy, while transient early wheezing was associated with day-care attendance. An association with eczema was found for all three childhood wheezing phenotypes. The association of allergic symptoms with sensitization is significant in the older but less pronounced in pre-school children and is more pronounced for current allergic symptoms. Diagnosis and disease definition of allergy symptoms remains difficult at pre-school age. The influence of a positive family history of allergy on the association of the respective allergic symptoms with sensitization was most important for eczema. Our data confirm the atopic characteristics of the different wheeze phenotypes.

The protective effect of community factors on childhood asthma

BACKGROUND

Asthma burden in the US is not evenly distributed. Although asthma prevalence varies widely across urban neighborhoods, little attention has been paid to the community as a key contributor.

OBJECTIVE

To determine the effect of positive socio-environmental community factors on childhood asthma prevalence in Chicago.

METHODS

From 2003 to 2005, an asthma screening survey was conducted among children attending Chicago Public/Catholic schools from kindergarten through eighth grade. One hundred five schools participated, yielding a stratified representation of 4 race-income groups. Positive community factors, such as social capital, economic potential, and community amenities, were assessed by using the Metro Chicago Information Center's Community Vitality Index.

RESULTS

Of the surveys returned, 45,177 (92%) were geocoded into 287 neighborhoods. Neighborhoods were divided into quartile groups by asthma prevalence (mean, 8%, 12%, 17%, 25%). Community vitality (54% vs 44%; P < .0001) and economic potential (64% vs 38%; P < .0001) were significantly higher in neighborhoods with low asthma prevalence. Neighborhood interaction (36% vs 73%; P < .0001) and stability (40% vs 53%; P < .0001) were significantly higher in neighborhoods with high asthma prevalence. Overall, positive factors explained 21% of asthma variation. Childhood asthma increased as the black population increased in a community (P < .0001). Accordingly, race/ethnicity was controlled. In black neighborhoods, these factors remained significantly higher in neighborhoods with low asthma prevalence. When considered alongside socio-demographic/individual characteristics, overall community vitality as well as social capital continued to contribute significantly to asthma variation.

CONCLUSION

Asthma prevalence in Chicago is strongly associated with socio-environmental factors thought to enrich a community. A deeper understanding of this impact may lend insight into interventions to reduce childhood asthma.

Body mass index in Belgian schoolchildren and its relationship with sensitization and allergic symptoms

Results of studies of the influence of body mass index (BMI) on the allergic status are controversial. As a part of the Aalst Allergy Study, we assessed the prevalence of the different BMI categories (underweight, normal weight, overweight, and obesity) and a possible association between BMI and atopy in 1576 unselected Belgian schoolchildren, aged from 3.4 to 14.8 yr. BMI was used to determine weight status. Skin prick testing with the most common aeroallergens was performed. A parental questionnaire documented data on respiratory and allergic disorders, demographic characteristics and other potential risk factors for sensitization. Among the total children, 4.1% of the children were underweight, 14.5% were overweight, and 7.4% were obese. More girls than boys were overweight (p = 0.015). In the group of children older than 12 yr, we found more overweight (p = 0.03) and obese (p = 0.004) girls, and more obese boys (p = 0.004) than in the younger age groups. In contrast with reports in the literature, an increased prevalence of allergic sensitization in underweight girls only [adjusted odd ratio (OR(adj)) = 2.9, 95% confidence interval (CI): 1.3-6.4] was documented. A strong association between obesity and exercise-induced respiratory symptoms was found in both boys (OR(adj) = 14.5, 95% CI: 2.9-73.3) and girls (OR(adj) = 4.9, 95% CI: 1.3-17.4). No correlations with allergic respiratory symptoms, eczema, or rhinoconjunctivitis could be documented.

The prevalence, characteristics of and risk factors for eczema in Belgian schoolchildren

Childhood eczema is common in infants, but its nature and extent during later childhood remains unclear. In this cross-sectional study we examined the prevalence and characteristics of eczema in an unbiased community population of 2,021 Belgian schoolchildren, aged 3.4 to 14.8 years with skin prick testing and parental questionnaires. Our study identified an eczema prevalence of 23.3% and a considerable allergic comorbidity, mainly in sensitized children. The reported prevalence of eczema in infancy was 18.5% and for current eczema 11.6%. The overall sensitization rate (33.2%) as well as sensitization rates for the individual allergens were significantly higher in children with "eczema ever." Sensitization to Dermatophagoides pteronyssinus (19.6%), mixed grass pollen (15.1%), and cat (9.1%) were most common. Until the age of 6 years, boys with eczema were significantly more sensitized than girls (p = 0.007). Children with both eczema in infancy and current eczema show a tendency to be more sensitized than children with eczema in infancy only or current eczema only, but significance was only noted for a few individual allergens. Analysis of factors associated with eczema revealed a predominantly atopic profile characterized by family or personal history of allergy. Breastfeeding and environmental factors seemed to assume little relevance except for a protective effect of prematurity and having a dog at birth.

Children with asthma miss more school: fact or fiction?

BACKGROUND

It is widely believed that children with asthma miss considerably more school than children without asthma. Previous surveys have indicated that 49% of children with asthma miss school (Asthma in America, 1998), but only a few studies have attempted to quantify the amount of school missed. Understanding the role of asthma in school attendance will help direct limited health-care resources to the children who need them most.

METHODS

We investigated school absence rates in fourth- through sixth-grade students in 19 inner-city schools in the Dallas Independent School District (DISD). The sample consisted of 353 students who were identified as possibly having asthma based on responses to a modified Brief Pediatric Screen instrument and who underwent spirometry and/or exercise challenge (EC) testing to confirm the diagnosis of asthma: 25 students were excluded for FEV(1) < 70% and without bronchodilator response, while 157 students had EC-positive test results, and 171 students had EC-negative test results. We compared yearly absences for these students with each other, with all fourth- through sixth-grade students in the 19 study schools, and with all fourth- through sixth-grade students in the district. We also tabulated data from a separate database that included asthma patients identified by the school registered nurse (RN). Absence data by school and by grade level were provided by the school district for the 2002-2003 school year.

RESULTS

Absence rates were as follows: 2.54% (EC positive), 2.12% (EC negative), 2.59% (abnormal FEV(1)), 2.86% (RN identified), 2.85% (all fourth- through sixth-grade students in study schools), and 2.95% (all fourth- through sixth-grade students in the DISD).

CONCLUSION

Students with asthma in the DISD miss no more school their classmates without asthma.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Parental language and asthma among urban Hispanic children

BACKGROUND

Many Hispanics in the United States have limited English proficiency and prefer communicating in Spanish. Language barriers are known to adversely affect health care quality and outcomes.

OBJECTIVE

We explored the relationship between parent language preference in a Hispanic population and the likelihood that a child with symptoms receives a diagnosis of asthma.

METHODS

We conducted a school-based survey in 105 Chicago public and Catholic schools. Our sample included 14,177 Hispanic children 6 to 12 years of age with a parent who completed an asthma survey. Outcomes of diagnosed asthma and possible asthma (asthma symptoms without diagnosis) were assessed by using the Brief Pediatric Asthma Screen Plus instrument.

RESULTS

Overall, 12.0% of children had diagnosed asthma, and 12.7% had possible asthma. Parents of children at risk who completed the survey in English reported higher rates of asthma diagnosis compared with parents who completed it in Spanish (55.2% vs 36.3%, P < .001). Predictors of asthma diagnosis were child sex, parental language preference, parental asthma status, and other household members with asthma.

CONCLUSIONS

Parental language preference might be an important characteristic associated with childhood asthma diagnosis. Whether language itself is the key factor or the fact that language is a surrogate for other attributes of acculturation needs to be explored.

CLINICAL IMPLICATIONS

Our findings suggest that estimates of asthma among Hispanic schoolchildren might be low because of underdiagnosis among children whose parents prefer communicating in Spanish.

Targeting improvements in asthma morbidity in Chicago: a 10-year retrospective of community action

Chicago has been described as "asthma ground zero" due to its disproportionately high rates of asthma-related hospitalization and mortality. Asthma prevalence rates in Chicago are higher for whites and African Americans than the national average. In an effort to address the asthma burden and disparities in Chicago, multiple initiatives throughout the city have been launched and continue due largely to the support of the Otho S.A. Sprague Memorial Institute. The purpose of this article is to describe the policy, advocacy, educational, surveillance, research, quality improvement, community, and consortia activities over the past 10 years and their impact on asthma morbidity and disparities in Chicago.

The influence of age and gender on sensitization to aero-allergens

Boys run a higher risk for atopy than girls but this gender difference is less pronounced in adulthood. The underlying mechanisms and the exact timing of this decrease in male/female ratio remain unclear. The aim of this study was to evaluate the effect of age and gender on sensitization in schoolchildren. A cross-sectional study was performed in an unbiased community population of 2021 Belgian schoolchildren, aged 3.4-14.8 yr. The overall sensitization and the sensitization for mites, mixed grass pollens and tree pollens increased significantly with increasing age. Male sex was strongly associated with sensitization (OR(adj) 2.0, 98% CI 1.6-2.4). Male predominance was more obvious in children under the age of 8 yr. After the age of 8 male predominance persisted, but a significant increase in sensitized females occurred. Our data demonstrate a significant increase in prevalence of sensitization with age and a significant decrease in male/female ratio of sensitization after the age of 8 yr, although a male predominance persists. These data are the first published data ever that document this change in male/female ratio in sensitization at this age.

The influence of atopic status and potential risk factors for sensitization on histamine skin reactivity in unselected Belgian children

The histamine skin response is widely used as a standardized positive control in the performance of skin prick testing. As a part of the Aalst Allergy Study, we investigated whether histamine skin reactivity, using histamine 10 mg/mL, was influenced by age, gender, ethnic origin, environmental exposure, specific sensitization patterns, or other factors. The parents of 2021 nonselected children aged 3.4-14.8 years completed a baseline questionnaire and gave written informed consent for skin prick testing with seven common aeroallergens on their child. Sensitized children had significantly larger histamine wheal sizes than nonsensitized children (mean 4.3 vs 4.0 mm, p < 0.05). A significant difference was found in histamine wheal size between nonsensitized versus multiply sensitized children (p < 0.001), but not between mono-sensitized versus multiply sensitized children (p = 0.105). The only other factors associated with significantly larger histamine wheal sizes were a history of eczema and a history suggestive for asthma on the Brief Pediatric Asthma Screen Plus. The histamine wheal was absent in 8.9% of children. In conclusion, sensitization and some other clinical indicators of atopy were associated with a larger histamine skin wheal. Other conditions including gender and environmental exposure did not have an influence on histamine skin reactivity, which strengthens the use of histamine as a reference in skin prick testing in this age group.

The effects of acculturation on asthma burden in a community sample of Mexican American schoolchildren

OBJECTIVES

We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma.

METHODS

Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance.

RESULTS

Caregivers' level of acculturation was associated with children's diagnosed asthma (P = .025) and total asthma (P = .078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR] = 1.12, P= .005) and children's insurance, both public (OR = 4.71, P= .009) and private (OR = 2.87, P= .071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P= .001).

CONCLUSIONS

The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk.

The International Study of Wheezing in Infants: questionnaire validation

BACKGROUND

There are no internationally validated questionnaires to investigate the prevalence of infant wheezing. This study was undertaken to validate a questionnaire for the International Study on the Prevalence of Wheezing in Infants (Estudio Internacional de Sibilancias en Lactantes, EISL).

MATERIAL AND METHODS

Construct and criterion validity were tested for the question 'Has your baby had wheezing or whistling in the chest during his/her first 12 months of life?'. Construct validity (i.e. the ability of parents and doctors to refer to the same symptoms with the same words) was tested in a sample of 50 wheezing and 50 non-wheezy infants 12-15 months of age in each of 10 centres from 6 different Spanish- or Portuguese-speaking countries. Criterion validity (i.e. the ability of parents to correctly detect the symptom in the general population) was evaluated in 2 samples (Santiago, Chile and Cartagena, Spain) of 50 wheezing and 50 non-wheezing infants (according to parents) of the same age, randomly selected from the general population, who were later blindly diagnosed by a paediatric pulmonologist.

RESULTS

Construct validity was very high (kappa test: 0.98-1) in all centres. According to Youden's index, criterion validity was good both in Cartagena (75.5%) and in Santiago (67.0%). Adding questions about asthma medication did not improve diagnosis accuracy.

CONCLUSIONS

The EISL questionnaire significantly distinguished wheezy infants from healthy ones. This questionnaire has a strong validity and can be employed in large international multicentre studies on wheezing during infancy.

Prevalence of childhood asthma and control in children assessed in a pilot school-based intervention programme in Singapore

AIM

Because of a high childhood asthma burden in Singapore, assessment of disease control status is essential for formulating school-based strategy of childhood asthma control. The aim of the present study is to assess childhood asthma prevalence and control in Singapore and the socio-demographic and help-seeking correlates.

METHODS

School-based survey using parental self-administered questionnaire, conducted from February to April 2004. Four mixed-gender primary schools selected from geographically distinct zones of Singapore. All primary one (modal age - 6.5 years) and six (modal age - 11.9 years) students from selected schools were invited to participate. Questionnaire respondents were the students' parents or guardians. The response rate was 75.2% (2123/2825).

RESULTS

Prevalence of current asthma was 8.9% (190/2123). Among them, 26.3% (46/175) were assessed to have inadequate control. Asthma was more prevalent, and less adequately controlled in children from lower socio-economic backgrounds (lower-end housing type). Children with poorly controlled asthma were more likely to be treated by emergency room physicians and hospital specialists, and to be on preventer medications.

CONCLUSIONS

In Singapore, poor asthma control is found in a sizeable proportion of school children with asthma, is identifiable for high-risk groups of children from lower socio-economic backgrounds and having asthma-related attendance at the emergency rooms.

Validating an asthma case detection instrument in a Head Start sample

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

Context matters: a community-based study of maternal mental health, life stressors, social support, and children's asthma

OBJECTIVE

Recent national survey data indicate an overall asthma prevalence of 12.2% for children who are younger than 18 years. Previous research in clinical samples of children with asthma suggests that their mothers are at greater risk for symptoms of depression. We describe the relationship between maternal symptoms of depression and having a child with asthma in a community-based sample.

METHODS

After a school-based ascertainment of asthma and asthma symptoms in 15 low-income, racially/ethnically diverse public elementary schools, 1149 eligible mothers agreed to participate in a longitudinal study. Mothers either had a child with previously diagnosed asthma or a child with symptoms consistent with possible asthma or were in the randomly selected comparison group in which no child in the household had asthma. During the first interview, mothers responded to questions about their own life stressors, supports and mental health, and their children's health.

RESULTS

In bivariate analyses of a community-based sample of children who share low-income neighborhoods, mothers of children with diagnosed or with possible undiagnosed asthma had more symptoms of depression than did mothers of children who have no asthma. Mothers of children with diagnosed or with possible undiagnosed asthma also experienced more life stressors than did mothers of children without asthma. Using nested linear regression, we estimated a model of maternal symptoms of depression. Most of the variation in Center for Epidemiologic Studies-Depression score was accounted for by life stressors and social support. There were no independent effects of either asthma status or asthma status-specific child health status on maternal symptoms of depression.

CONCLUSION

Children who are under care for chronic conditions such as asthma live and manage their illness outside the clinical setting. Their social context matters, and maternal mental health is related to their children's physical health. Although having a child with asthma may be "just" another stressor in the mother's social context, complex treatment plans must be followed despite the many other pressures of neighborhood and family lives.

Racial and ethnic disparities in diagnosed and possible undiagnosed asthma among public-school children in Chicago

OBJECTIVES

We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools.

METHODS

We used the Brief Pediatric Asthma Screen Plus (BPAS+) and the Spanish BPAS+, validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools.

RESULTS

Among 11490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children.

CONCLUSIONS

There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities.

School-based asthma surveillance: a comparison of student and parental report

This study addressed the comparability of data obtained from a student-based and parent-based asthma and respiratory health survey. Our goal was to ascertain whether there were meaningful and systematic differences in asthma classification based on symptom and diagnosis reports obtained separately from students and their parents. A brief, written survey, based on the International Study of Asthma and Allergy in Children questionnaire, was administered to 6th through 10th grade students in two schools in Oakland, CA, USA. Students who reported asthma-like indicators for the previous 12-month period were defined as positive and a more extensive questionnaire was mailed home to those parents. A more refined classification of asthma based on parent report of indicators was compared with student report. Forty-four percent of 1298 students were classified as positive for current asthma-like symptoms and 50% of parent surveys were returned. For the positive students with parent surveys, 59% were classified as 'probable' for asthma based on the parent survey. Overall, the agreement between parent and students' classification was 70%, and 83% for students with a parent report of physician diagnosis of asthma. Students who were discordant with parents for physician diagnosis of asthma were more likely to be male, and more likely to have a parent report of unscheduled Emergency Department visit for wheezing or trouble breathing. Findings indicated that with the exception of medication, students reported asthma indicators more frequently that parents, independent of classification. Student report of physician diagnosis with a 12-month report of an asthma symptom was determined to be a good indicator of probable current asthma. Inclusion of or reliance on a parental questionnaire is not likely to improve the reliability of a school-based asthma surveillance program in our population.

Validation of the Spanish and English versions of the asthma portion of the Brief Pediatric Asthma Screen Plus among Hispanics

BACKGROUND

The health and health care needs of non-English-speaking Hispanic families with children are poorly understood, in part because they are often excluded from research owing to language barriers. Instruments that are valid in English and Spanish are necessary to accurately evaluate the magnitude of asthma prevalence and morbidity among Hispanics.

OBJECTIVE

To establish the sensitivity and specificity of the English and Spanish versions of the asthma portion of the Brief Pediatric Asthma Screen Plus (BPAS+) in a low-income Hispanic population.

METHODS

The validation sample consisted of 145 children whose parents completed the BPAS+ in Spanish and 78 whose parents completed it in English. Bilingual clinicians conducted the examinations on which the clinical assessments were based. We compared the BPAS+ results with the clinical assessment findings to determine the sensitivity and specificity of the BPAS + among Hispanics in terms of identifying children who warrant further medical evaluation for asthma.

RESULTS

The sensitivity and specificity of the asthma portion of the Spanish BPAS+ were 74% and 86%, respectively. The sensitivity and specificity of the asthma portion of the English BPAS+ were 61% and 83%, respectively.

CONCLUSIONS

The asthma portion of the BPAS+, a valid screen for identifying children who are in need of further evaluation for potentially undiagnosed asthma, is valid for low-income Hispanics in Spanish and English. As the Hispanic population continues to grow, it is imperative that researchers have English and Spanish instruments that are valid for this population.

Development and validation of school-based asthma and allergy screening questionnaires in a 4-city study

BACKGROUND

Asthma and allergies are commonly undiagnosed in children. Schools provide settings for potentially accessing almost all children for asthma and allergy screening.

OBJECTIVE

To evaluate the feasibility and validity of using a questionnaire-based screening tool to identify undiagnosed asthma and respiratory allergies in children in kindergarten to grade 6.

METHODS

A student questionnaire (SQ) and a parent questionnaire (PQ) were developed, administered in 4 diverse communities, and validated against standardized clinical assessments. Children without diagnosed asthma and representing a range of symptoms participated in a validation study that consisted of independent, standardized, clinical assessments. Sensitivity, specificity, and predictive values for questionnaire items were evaluated against expert consensus designations.

RESULTS

A total of 190 children (age range, 7-13 years) completed the validation study. Affirmative responses to individual questions from either the SQ or PQ regarding asthma and allergy were modestly to moderately predictive of the clinical assessments (odds ratios, generally 2.5-5.0). When considering a positive asthma screen as affirmative responses to 3 of the best 7 SQ asthma questions, the odds ratio for asthma was 9.3 (95% confidence interval, 4.1-21.1), with 80% sensitivity and 70% specificity. Considering the allergy screen as positive based on affirmative response to either of the 2 SQ allergy questions yielded 81% sensitivity and 42% specificity.

CONCLUSIONS

Either a 9-item SQ or a 10-item PQ can be used in diverse settings to screen for asthma and respiratory allergies. The SQ, obtained by directly screening students, may provide a sensitive approach for detecting children with previously undiagnosed asthma and allergies.