Current prevalence of asthma-related symptoms in San Diego's predominantly Hispanic inner-city children

Operational definitions of paediatric asthma used in epidemiological studies: A systematic review

Background

Researchers use different definitions to identify children with asthma in epidemiological surveys. We conducted a systematic review to describe the definitions used in epidemiologic studies for wheeze and asthma in the paediatric population, aimed to inform the development of a uniform definition of paediatric asthma for future epidemiological research.

Methods

We systematically searched terms to identify asthma and/or wheeze among children aged <13 years and published between 1995-2020 across seven databases (MEDLINE, EMBASE, PsycINFO, Global Health, AMED, LILACS and CINAHL). PRISMA guidelines were followed for this review.

Results

We extracted a total of 11 886 records, where 190 met our eligibility criteria and included in the analysis. Among the included studies, 62.1% (n = 118/190) used the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaires, predominantly in developing countries (80%, n = 64/80). ‘Wheeze’ was reported in five categories, subdivided by 14 different definitions. “Current wheeze”, defined as caregivers report of wheezing sounds from the chest of the child in the past 12 months and “Wheeze ever”, defined as caregivers’ report of wheezing or whistling in the chest of the child at any previous time, were the most common wheeze category reported in 129 and 95 studies, respectively. Asthma was reported in nine categories using 53 definitions. The most common asthma category was “Asthma ever”, which was reported in 89 studies, based on caregiver statement that the child had asthma in the past.

Conclusion

Definitions of wheeze and asthma for children used in surveys are primarily based on parent-reported clinical features. Studies from developing countries more frequently used the ISAAC definitions to report childhood asthma and wheeze compared to the studies from developed counties. The use of a uniform asthma definition will aid the interpretation of research findings globally.

Understanding sibilancias (wheezing) among Mexican American parents

BACKGROUND

Asthma is one of the most common pediatric chronic diseases in the United States; however, prevalence varies across Latino ethnicities, such as Mexican Americans (MAs). Linguistic and cultural issues may contribute to difficulties in diagnosis.

METHODS

We conducted a qualitative study to assess the comprehension of common words used in a validated asthma questionnaire. The study sample consisted of 40 MA Spanish-speaking parents of 2- to 18-year-old children, with and without asthma, at a community health clinic.

RESULTS

Regardless of their child's asthma status, the majority of parents (12 [80%] with non-asthmatic children; 16 [64%] with asthmatic children) did not understand common Spanish words used in clinical settings to identify asthma (e.g., wheezing and whistling). Instead, parents used physical symptoms and sounds to describe asthma.

CONCLUSION

This exploratory study demonstrates MA parents' limited comprehension of common words used in clinical settings to identify asthma. Future research should examine tools that incorporate visual and auditory descriptions of asthma.

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

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

A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program

The purpose of this study was to examine the challenges of integrating an asthma disease management (DM) program into a primary care setting from the perspective of primary care practitioners. A second goal was to examine whether barriers differed between urban-based and nonurban-based practices. Using a qualitative design, data were gathered using focus groups in primary care pediatric practices. A purposeful sample included an equal number of urban and nonurban practices. Participants represented all levels in the practice setting. Important themes that emerged from the data were coded and categorized. A total of 151 individuals, including physicians, advanced practice clinicians, registered nurses, other medical staff, and nonmedical staff participated in 16 focus groups that included 8 urban and 8 nonurban practices. Content analyses identified 4 primary factors influencing the implementation of a DM program in a primary care setting. They were related to providers, the organization, patients, and characteristics of the DM program. This study illustrates the complexity of the primary care environment and the challenge of changing practice in these settings. The results of this study identified areas in a primary care setting that influence the adoption of a DM program. These findings can assist in identifying effective strategies to change clinical behavior in primary care practices.

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

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

Symptom profile and asthma control in school-aged children

BACKGROUND

Children with poorly controlled asthma are at high risk of airway remodeling, sleep disruption, school absenteeism, and limited participation in activities.

OBJECTIVE

To determine asthma prevalence and characterize disease severity and burden in school-aged children.

METHOD

A case-finding study was conducted via a multiple-choice questionnaire and asthma algorithm. Items used for analysis include physician diagnosis of asthma, symptom severity, and health care utilization. The chi2 test was used to determine the significance of differences among cases. Logistic regression was used to evaluate the association of patient factors and asthma indicators.

RESULTS

Of the 5,417 children surveyed, 1,341 (25%) were classified as being at risk of asthma. Of these asthma cases, 55% were positive by diagnosis and algorithm (active), 10% were positive per algorithm alone (suspected), and 35% were positive per diagnosis alone (nonactive). Only 14% of all asthma cases reported experiencing no respiratory symptoms (< 1% active, 2% suspected, and 40% nonactive) compared with 75% of noncases. Also, 75% of noncases reported never missing school compared with 19%, 33%, and 54% of active, suspected, and nonactive asthma cases. African American race, Medicaid enrollment, and male sex were independent predictors of asthma risk. Similarly, African American race, Medicaid enrollment, age, and persistent asthma were independent predictors of emergency department use among asthma cases.

DISCUSSION

Prevalence of active symptoms suggestive of poor asthma control was extremely high among urban, minority children enrolled in Arkansas' largest public school district. Poor asthma control greatly affects quality of life, including school attendance and performance. Interventions should raise expectations and emphasize the importance of achieving asthma control.

Asthma in Hispanics

Hispanic individuals trace their ancestry to countries that were previously under Spanish rule, including Mexico, large parts of Central and South America, and some Caribbean islands. Most--but not all--Hispanics have variable proportions of European, Amerindian, and African ancestry. Hispanics are diverse with regard to many factors, including racial ancestry, country of origin, area of residence, socioeconomic status, education, and access to health care. Recent findings suggest that there is marked variation in the prevalence, morbidity, and mortality of asthma in Hispanics in the United States and in Hispanic America. The reasons for differences in asthma and asthma morbidity among and within Hispanic subgroups are poorly understood but are likely due to the interaction between yet-unidentified genetic variants and other factors, including environmental tobacco smoke exposure, obesity, allergen exposure, and availability of health care. Barriers to optimal management of asthma in Hispanics in the United States and in Hispanic America include inadequate access to health care, suboptimal use of antiinflammatory medications, and lack of reference values for spirometric measures of lung function in many subgroups (e.g., Puerto Ricans). Future studies of asthma in Hispanics should include large samples of subgroups that are well characterized with regard to self-reported ethnicity, country of origin, place of birth, area of residence, and indicators of socioeconomic status. Because Hispanics are disproportionately represented among the poor in the United States, implementation of adequate access to health care and social reforms (e.g., improving housing conditions) would likely have a major impact on reducing asthma morbidity in this population.

Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

OBJECTIVES

To determine whether an organized, citywide asthma management program delivered by primary care providers (PCPs) increases adherence to the National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines and whether adherence to the guidelines by PCPs decreases medical services utilization in low-income, minority children.

STUDY DESIGN

Analysis of the utilization of medical services for a cohort of 3748 children with asthma who presented for care at one of six primary care urban clinics in Hartford, Connecticut, and who were enrolled in a disease management program (Easy Breathing) between June 1, 1998 and August 31, 2002.

RESULTS

Of the 3748 children with physician-confirmed asthma, 48% had persistent disease. Paid claims for inhaled corticosteroids increased 25% ( P <.0001) after enrollment in Easy Breathing. Provider adherence to the NAEPP guidelines for anti-inflammatory therapy increased from 38% to 96%. Easy Breathing children with asthma experienced a 35% decrease in overall hospitalization rates ( P <.006), a 27% decrease in asthma emergency department (ED) visits ( P <.01), and a 19% decrease in outpatient visits ( P <.0001).

CONCLUSIONS

An organized, disease management program increased adherence to the NAEPP guidelines for anti-inflammatory use by PCPs in urban clinics. Adherence to this element of the guidelines by PCPs reduced hospitalizations, ED visits, and outpatient visits for children with asthma.

Effect of asthma intervention on children with undiagnosed asthma

OBJECTIVE

To measure the effect of an asthma intervention on the functional status and morbidity of children with undiagnosed asthma.

STUDY DESIGN

Data from a randomized trial were used to compare outcomes at baseline and follow-up for children with undiagnosed and diagnosed asthma. We studied 510 symptomatic children with diagnosed asthma (diagnosed) and 299 children with symptoms but no diagnosis (undiagnosed). Baseline functioning and morbidity were similar for undiagnosed and diagnosed patients classified as moderate-severe.

RESULTS

There were fewer undiagnosed reported allergies, seasonal symptoms, and other respiratory diagnoses (all P < 0.01). Among the moderate-severe, functional status, for example, symptom-days ( P = .02), symptom-nights ( P < .01), and days of restricted activity ( P < .01), was significantly reduced at follow-up for the undiagnosed in the intervention group but not for undiagnosed control subjects. Findings were similar for children with diagnosed asthma.

CONCLUSIONS

Children with undiagnosed asthma were generally nonatopic, although some had symptoms at a level comparable to children with a diagnosis. The intervention successfully improved functional status for children with undiagnosed asthma as well as for children with diagnosed asthma. These results can be applied to ongoing discussions related to case detection.

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

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

Childhood asthma on the northern Mexico border

Children with asthma living on the northern Mexico border suffer not only from the physical aspects of this condition, but also from the lack of a clear biomedical definition and treatment plan for the illness. An ethnographic study involving participant observation and focused interviews in Tijuana, Mexico, sought to understand the intersection of diagnostic uncertainties surrounding childhood asthma on the part of parents, particularly mothers, living in acute poverty. Environmental factors such as dust and insects in impoverished homes probably acted as asthma triggers among many of the children in the study. Furthermore, management of children's asthma took place not only in biomedical clinics, but also in homes, traditional medical settings, and pharmacies, where mothers often sought remedies for their children's asthma attacks on an emergency basis. In all treatment settings, including biomedical ones, they often faced significant barriers to effective care, including the misuse of antibiotics. Thus, the role of pharmaceutical sales clerks, as well as pediatric asthma specialists, is explored in this article.

Prevalence of childhood asthma and associated morbidity in Los Angeles County: impacts of race/ethnicity and income

Racial/ethnic and socioeconomic disparities in the prevalence of childhood asthma have been reported nationally but few population-based studies in local and regional settings have been reported. To assess variation in the prevalence of childhood asthma and associated morbidity across race/ethnic and income groups in the Los Angeles County population, we analyzed data on a random sample of 6004 children (< or = 17 years old) enrolled in a countywide health survey from September 1999 through April 2000. The prevalence of childhood asthma was highest in blacks (15.8%), intermediate in whites (7.3%) and Asians (6.0%), and lowest in Latinos (3.9%; p < 0.001). These differences persisted after controlling for income, measures of health care access, and other covariates. Asthma prevalence was inversely related to income in all racial/ethnic groups except Latinos from Spanish-speaking households. Among children with asthma, blacks and Latinos were more likely than whites to report asthma-related limitations in physical activity and need for urgent medical services. These findings indicate marked disparities in asthma prevalence and related morbidity in this large urban child population and highlight the importance of efforts to identify high-risk subpopulations for focused prevention and treatment interventions.

Assessment of respiratory symptoms and asthma prevalence in a U.S.-Mexico border region

The authors studied children who were 10-12 yr of age and who resided in sister cities in a U.S.-Mexico border region to determine the prevalence of asthma and respiratory symptoms. The relationship of symptoms to ambient levels of particulate matter less than 10 microm in diameter (PM10), and to several indoor environmental conditions, was assessed. The study was conducted in the border cities of Ambos Nogales (Nogales, Arizona [United States], and Nogales, Sonora [Mexico]). At the beginning of the 11-wk study, during the autumn of 1996, 631 students and their parents completed baseline questionnaires. While in school, the children completed daily symptom diaries and daily peak expiratory flow maneuvers. PM10 values and daily temperatures were also measured. The authors found that the prevalence of self-reported asthma among 5th-grade students was comparable on both sides of the border (i.e., 7.6% on the Arizona side and 6.9% on the Sonora side). Wheezing was a frequent complaint (29.5-35.6%), as was cough (16.8-29.6%). Smoking in the home was common on both sides of the border, and it was associated with a greater occurrence of self-reported asthma and respiratory complaints. Increased respiratory symptoms were also associated with increased ambient PM10 levels. The prevalence of respiratory symptoms such as wheezing and frequent cough among all children in this study, combined with the limitations inherent in self-reporting, suggest that asthma may actually be more prevalent than has been previously reported.

Childhood asthma in an urban community: prevalence, care system, and treatment

OBJECTIVES

We describe the system of asthma care in Hartford, CT, an urban, minority community.

METHODS

The health field concept was used to organize factors influencing asthma prevalence and severity. Data were obtained from national, state, and municipal reports, and from surveys of children in Hartford seeking medical care in an asthma program called Easy Breathing.

RESULTS

Between June 1, 1998, and May 1, 2000, 21% of children receiving Medicaid in Hartford did not file a medical claim. Between 1998 and 2000, the number of providers in Hartford decreased by 37% while the number of outpatient visits increased by 8%. Using claims data, we found the following: 19.0% of Hartford children had asthma (data from the International Classification of Disease, ninth revision, and the National Drug Code); and 12% of children with asthma filled a prescription for inhaled corticosteroid therapy, 83% for a bronchodilator, and 36% for an oral corticosteroid. Children with asthma were more likely to be hospitalized (10% vs 5%, respectively) and to visit an emergency department (45% vs 29%, respectively), and, on average, they had more hospital days (0.603 vs 0.415 days per child, respectively) and more outpatient visits per year (4.7 vs 2.5 visits, respectively) compared to children without asthma. Asthma prevalence in the 6,643 children surveyed in the Easy Breathing program was 41%. Persistent asthma was diagnosed in 50% of the children with asthma. Asthma prevalence varied by ethnic origin, age, and gender, and was highest in Hispanic/Puerto Rican children, in children 5 to 10 years of age, in boys up to 10 years of age, and in girls after 15 years of age.

CONCLUSION

Improved personal behaviors and medical care will have a limited sustained impact on childhood asthma until basic environmental issues are modified. The health field concept provides a mechanism with which to address the issues surrounding asthma in urban communities.

Asthma management and environmental tobacco smoke exposure reduction in Latino children: a controlled trial

OBJECTIVES

This study tested the efficacy of coaching to reduce environmental tobacco smoke (ETS) exposure among asthmatic Latino children.

DESIGN

After asthma management education, families were randomly assigned to no additional service (control condition) or to coaching for ETS exposure reduction (experimental condition).

SETTING

The study was conducted in San Diego, California.

PARTICIPANTS

Two hundred four Latino children (ages 3-17 years) with asthma participated.

INTERVENTION

Approximately 1.5 hours of asthma management education was provided; experimental families also obtained 7 coaching sessions ( approximately 45 minutes each) to reduce ETS exposure.

OUTCOME MEASURES

Reported ETS exposure and children's urine cotinine were measured.

RESULTS

Parents in the coached condition reported their children exposed to significantly fewer cigarettes than parents of control children by 4 months (postcoaching). Reported prevalence of exposed children decreased to 52% for the coached families, but only to 69% for controls. By month 4, mean cotinine levels decreased among coached and increased among control children. Cotinine prevalence decreased from 54% to 40% among coached families, while it increased from 43% to 49% among controls. However, cotinine levels decreased among controls to the same level achieved by coached families by the 13-month follow-up.

CONCLUSIONS

Asthma management education plus coaching can reduce ETS exposure more than expected from education alone, and decreases in the coached condition may be sustained for about a year. The delayed decrease in cotinine among controls is discussed.

Serving the underserved: school-based asthma intervention programs

Asthma is a common and costly disease, which disproportionately affects young, ethnic minority, and impoverished individuals. A heightened public awareness has catalyzed a variety of efforts to reduce the impact of childhood asthma in the United States. Despite these efforts, however, at-risk groups continue to suffer excess morbidity. Strategies are required that can specifically address the needs of underserved communities. We review the underlying rationale and progress of school-based programs designed to assist asthmatic children.

Influence of sociodemographics on the health-related quality of life of pediatric patients with asthma and their caregivers

The relationship between socioeconomic variables and the health-related quality of life (HQL) of children with asthma and their caregivers was examined. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ) were administered to 99 pediatric asthmatic patients and caregivers in two specialty clinics. Sociodemographic data was obtained from medical records and additional questions. The relationship between sociodemographic variables and HQL was determined using multiple linear regression. The mean patient age was 12.6+/-2.1 years, more were male and from a minority race. The mean age of caregivers was 41.2+/-8.5 years; most were female and were fom a minority race. Patients tended to rate their asthma severity as mild to moderate, while caregivers tended to rate patients in the moderate to severe category. Based on prescribed medications, most patients had mild to moderate asthma. Household income was consistently associated with patient-perceived HQL. Less consistent associations were seen with other variables. Household income and the caregiver's perception of asthma severity were associated with all caregiver HQL domains. It was concluded that household income was most consistently associated with the HQL of asthmatic pediatric patients and their caregivers.

Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans

This study reports on community surveys of 160 representative Latino adults in Hartford, CT, Edinburg, TX, Guadalajara, Mexico; and in rural Guatemala. A 142-item questionnaire covered asthma beliefs and practices (e.g., causes, symptoms, and treatments). The cultural consensus model was used to analyze the agreement among respondents within each sample and to describe beliefs. Beliefs were then compared across the four samples. Analysis of the questionnaire data shows that there was overall consistency or consensus regarding beliefs and practices among individuals at each site (intraculturally) and to a lesser extent across respondents of all four different Latino cultural groups (i.e., interculturally). This pattern of response is indicative of a shared belief system among the four groups with regard to asthma. Within this shared belief system though, there is systematic variation between groups in causes, symptoms, and treatments for asthma. The most widely recognized and shared beliefs concerned causes of asthma. Notable differences were present between samples in terms of differences in beliefs about symptoms and treatments. The biomedical model is shown to be a part of the explanatory model at all sites; in addition to the biomedical model, ethnocultural beliefs such as the humoral ("hot/cold") aspects and the importance of balance are also evident. The Connecticut Puerto Ricans had a greater degree of shared beliefs about asthma than did the other three samples (p < 0.00005). It was concluded that the four Latino groups studied share an overall belief system regarding asthma, including many aspects of the biomedical model of asthma. In addition, traditional Latino ethnomedical beliefs are present, especially concerning the importance of balance in health and illness. Many beliefs and practices are site-specific, and caution should be used when using inclusive terms such as "Hispanic" or "Latino," since there is variation as well as commonality among different ethnic groups with regard to health beliefs and practices.

Diagnosing pediatric asthma: validating the Easy Breathing Survey

OBJECTIVE

To determine the sensitivity, specificity, and predictive value of a simple, self-administered questionnaire for the diagnosis of asthma in children.

STUDY DESIGN

A questionnaire specifically designed to assist primary care providers in making a diagnosis of asthma in children was developed and administered in 4 different primary care and subspecialty clinics, validated, and then used as part of an asthma management program called Easy Breathing. Asthma diagnoses were made according to recommended National Asthma Expert Panel Guidelines.

RESULTS

Four questions on the survey were shown to be sensitive and specific for asthma. The sensitivity was greater for all levels (mild, moderate, and severe) of persistent asthma than for mild, intermittent asthma. A positive response to any 1 of the 4 questions was over 94% sensitive for asthma; a negative response to all 4 questions was 55% specific for ruling out asthma.

CONCLUSIONS

Patient responses to 4 specific respiratory symptom questions can assist primary care providers in diagnosing asthma in children. Primary care providers serving pediatric populations at high risk for asthma should consider asking patients or their parents these 4 questions regarding asthma symptoms on a regular basis.

School-based identification of asthma in a low-income population

The increase in the prevalence, morbidity, and mortality of asthma among children over the last decade has been well documented, especially among low-income minority children. Hypotheses for the increases in morbidity and mortality include limited access to primary care services and the failure to recognize the presence and severity of asthma. The University of Miami Pediatric Mobile Clinic (Mobile Clinic) Asthma Intervention Program is designed to identify underserved asthmatic children at school and offer them culturally sensitive care. Nine elementary schools with low income, predominantly Hispanic and African-American populations regularly served by the Mobile Clinic, were chosen for study participation. All 5,800 students who were enrolled in kindergarten through third grade were given letters at the time of registration by their homeroom teachers about the asthma program. Caretakers who returned the questionnaire and reported that the student had asthma symptoms were invited to have the student undergo a medical evaluation in the Mobile Clinic. Over a 2-year period, caretakers of 423 students (7.3% of all students) expressed an interest in further evaluating their child's respiratory health. Of these, we enrolled and evaluated 154 in the Mobile Clinic's Asthma Intervention Program. The Mobile Clinic physicians identified 145 of the enrollees as having asthma. These results indicate that in elementary schools serving predominantly low-income minority populations, a large fraction of the asthmatic population (estimated prevalence, 6-10%) can be identified by a school-based letter. Further, in a subset of asthmatic students (children of interested caretakers), there is good agreement between caretaker responses and physician diagnosis of asthma. Since school attendance is mandatory, school-based methods may be an effective method for identifying low-income children with asthma.

[Features of patients with bronchial asthma seen at the emergency department of a referral hospital in a semirural area]

Bronchial asthma is a chronic disease whose prevalence and severity is increasing. Appropriate treatment of exacerbation seems to affect the subsequent course of disease.

OBJECTIVES

To assess the extent of application of guidelines for treating exacerbations of asthma and to describe the clinical and epidemiological characteristics of patients.

PATIENTS AND METHODS

All patients presenting with exacerbations to the emergency room of a referral hospital in a semi-rural area of Catalonia were enrolled consecutively. We recorded symptoms, function and treatment variables during the emergency and when the patient was stable, at which time we also administered the Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

Forty-seven percent of patients resided in rural villages. Seventy-one percent lived in the area served by our hospital. Of the remaining patients, 57% came from municipalities in the Baix Empordà area, 29% in Alt Empordà area and 14% in La Selva area. Seventy-one percent went to the hospital directly from home, 66% of them were in the province of Girona; 75% of those homes were within urban areas. Of the 29% who had been sent to the emergency room by a physician, 71% were from a rural area. The 119 asthma exacerbations treated (114 patients, 71 females, 42 +/- 23 years) accounted for 0.3% of all emergency room visits. The exacerbation was considered severe in 31%, moderate in 47% and mild in all remaining cases. Eighty-eight percent of patients had experienced an exacerbation before. Symptoms were often present before the attack, but nearly half the patients were receiving relatively inadequate medication. Peak expiratory flow and oxygen saturation were recorded in 70% of cases and both variables improved after initial treatment (250 +/- 97 to 349 +/- 92 l/min, p < 0.001; and 92 +/- 7 to 96 +/- 2%, p < 0.01, respectively). All patients received inhaled salbutamol, 44% inhaled corticosteroids and 73% intravenous corticosteroids. A quarter of the patients were admitted to the ward (0.4% of all admissions) and 4% were admitted to the intensive care unit. Patients stayed 8.8 +/- 1.4 h in the emergency room. When patients were stable, asthma was severe in 14%, moderate in 42%, mild but persistent in 27%, and occasional in 17%. The total score on the AQLQ was 13.8 +/- 11.1, with mood being the dimension with the highest score (5.1 +/- 4.9). This score, along with social restriction, were lowest in the group of patients with chronic airflow obstruction.

CONCLUSIONS

Nearly half the patients were from rural villages most of which were located outside the zone served directly by our hospital. The preference for specialized medical attention would explain the percentage of patients seen who did not belong to the assigned area. Difficulty of access to the hospital from certain rural areas would account for the greater number of rural patients who had been referred by a physician. Clinical management and monitoring of asthmatic patients with exacerbation could be improved by greater diffusion and application of guidelines. It would be interesting to incorporate come sort of questionnaire on quality of life while taking a patient's history.

An English and Spanish Pediatric Asthma Symptom Scale

BACKGROUND

Pediatric asthma survey measures have not been adequately tested in non-English-speaking populations.

OBJECTIVES

To test the reliability and validity of an English and Spanish symptom scale to measure asthma control in children.

SUBJECTS

Parents (54% Spanish-speaking; 61% not high school graduates) of 234 children seen in the emergency department for an asthma exacerbation.

MEASURES

Parent report of frequency and perceived severity of child asthma symptoms during the beginning and after resolution of the exacerbation.

RESULTS

An 8-item scale composed of reports of cough, wheezing, shortness of breath, asthma attacks, chest pain, night symptoms, and overall perceived severity had very good psychometric properties in both English and Spanish. The reliability (Cronbach's alpha) of the scale ranged from 0.81 to 0.87 for both languages and time frames. In both languages, the validity of the scale was supported by responsiveness to changes in clinical status (lower symptom score after resolution of the exacerbation, P < 0.001) and by moderate to strong correlations (P < 0.001) with other asthma morbidity measures (parent report of child bother: r = 0.59-0.65; school days lost: r = 0.38-0.67; and activity days lost: r = 0.41-0.59). There were no statistically significant differences in the reliability or construct validity of the summary symptom scale by language, although Spanish speakers reported a lower frequency of some symptoms than did English speakers.

CONCLUSIONS

A reliable and valid 8-item scale can be used to measure control of asthma symptoms in Spanish-speaking populations of low literacy. Additional research to evaluate language equivalency of asthma measures is necessary.

Asthma hospitalization trends in California, 1983-1996

Annual asthma hospitalization rates were calculated for California's ethnically diverse population from 1983 through 1996. Trends were examined for four race/ethnicity groups: Hispanics, African-Americans, non-Hispanic Caucasians, and Asians/Pacific Islanders. The overall rate decreased by 30% during the time period. African-Americans had the highest rate, more that three times greater than the rate for Caucasians. Among children, the rates for Caucasians decreased by one-third, while rates increased for Hispanics and Asians. The rate for African-American children remained generally constant and was four times higher than the rate for Caucasians. Data from 1996 were assessed for repeat admissions, age and sex differences in rates, costs, and progress toward national goals.

Exploring lay definitions of asthma and interpersonal barriers to care in a predominantly Puerto Rican, inner-city community

Lay definitions of asthma were elicited through a single open-ended question from a population-based sample of mostly Puerto Rican, inner-city residents in Buffalo, New York. One hundred fifty-five household responses to the question, "What do you think asthma is?" were analyzed qualitatively using the editing approach. Five common codes emerged in order of significance: "symptoms," "disease," "triggers," "threat," and "coping." Overall, expressions of illness reflected a largely symptomatic perception of asthma regardless of asthma status. Perceptions of "disease" increased with higher level of education. Patients' definitions of illness should be considered to help reduce interpersonal barriers to asthma care.

Prevalence and burden of illness for asthma and related symptoms among kindergartners in Chicago public schools

BACKGROUND

Asthma mortality rates in poor communities of Chicago are among the highest in the country. Possible explanations include increased asthma prevalence, increased severity, and suboptimal health care.

OBJECTIVE

To estimate the prevalence of asthma and asthma-related symptoms among inner-city kindergarten children, and to characterize their burden of illness, asthma-related health care access, and pharmacologic treatment.

METHODS

Cross-sectional survey of parents of kindergartners was conducted in 11 randomly selected Chicago elementary schools. A self-administered 16-item questionnaire was given to parents of kindergartners. Parents who reported doctor-diagnosed asthma or at least one of several key asthma-related symptoms were then interviewed with a supplemental questionnaire examining asthma-related health care and medication use.

RESULTS

Based on data from 638 children [mean age 5.7 (SD = 0.6) years], the prevalence of diagnosed asthma was 10.8%. Sixteen percent of the respondents reported that their child had wheezed in the past year. The prevalence of asthma-related symptoms unassociated with a diagnosis of asthma was 30.1%. The children with diagnosed asthma had evidence of a high burden of illness: over 40% were reported to have had sleep disturbance due to wheezing > or =1 to 2 nights/week and 86.6% reported acute care visits for respiratory symptoms in the past year. Self-reported access to medical care was high. Over 40% of the children with doctor diagnosed asthma were reported to have used a beta2-agonist in the preceding 2 weeks, and 12.2% used an inhaled anti-inflammatory.

CONCLUSIONS

These data suggest that asthma prevalence in school-aged children in inner-city communities may be higher than US estimates. The burden of illness experienced by these children is substantial. Also, a large proportion of children were reported to have respiratory symptoms consistent with asthma, and no asthma diagnosis, suggesting possible undiagnosed asthma. While measures of health care access appear to indicate that the majority of children with asthma experience no identified barriers to health care, there is evidence to suggest undertreatment.

Socioeconomic factors and asthma hospitalization rates in New York City

Asthma morbidity and mortality are not distributed homogeneously among populations. To assess the relationship between asthma hospitalization rates and socioeconomic factors, we conducted an ecologic analysis using small geographical areas defined by postal zip code in New York City. Asthma hospitalization rates correlated with low median family income, percentage of minorities in the population, and percentage of children under the age of 18. Lack of access to preventive health care, poor housing conditions, environmental exposures, and genetic susceptibility may contribute to high incidence of asthma in some neighborhoods. This report supports the role of socioeconomic factors in asthma and serves to provide data for regulatory and health agencies to concentrate their efforts on neighborhoods most in need.

Changing prevalence of allergic rhinitis and asthma

OBJECTIVE

This review will enable the reader to discuss prevalence, risk factors, and prognosis of allergic rhinitis and asthma.

DATA SOURCES

MEDLINE (PubMed) search using the terms allergic rhinitis, asthma, prevalence, risk factors.

STUDY SELECTION

Human studies published in the English language since 1978, especially studies of relatively large populations in the United States, Great Britain, Australia, and New Zealand, with cross referencing to earlier relevant studies.

RESULTS

Current prevalence of allergic rhinitis at 16 years of age in cohorts of British children born in 1958 and 1970 increased from 12% in the earlier cohort to 23% and in the later cohort. Local surveys of allergic rhinitis at approximately 18 years of age in the United States in 1962 to 1965 disclosed prevalence of 15% to 28%, while the national survey of 1976 to 1980 disclosed a prevalence of 26%. Thus, it is uncertain whether prevalence of allergic rhinitis has changed in the United States based on these limited data. Data from several sources indicate worldwide increases in prevalence of asthma. Annual Health Interview surveys indicate increases in prevalence of asthma in the United States from 3.1% in 1980 to 5.4% in 1994, but prevalence among impoverished inner city children has been much higher. Combined prevalence of diagnosed and undiagnosed asthma among inner city children has been 26% and 27% at 9 to 12 years of age in Detroit and San Diego. Positive family history and allergy are important risk factors for allergic rhinitis and asthma. Prognosis is guarded; allergic rhinitis resolves in only 10% to 20% of children within 10 years, and at least 25% of young adults who have had asthma during early childhood are symptomatic as adults.

CONCLUSION

Increases in prevalence remain unexplained, but avoidance of recognized allergens should reduce the prevalence of allergic rhinitis and asthma.

The challenge of inner-city asthma

Racial and ethnic minorities of low socioeconomic status residing in urban environments currently referred to as inner cities appear to represent a population that is disproportionately at high risk for asthma morbidity and mortality. Epidemiologic studies suggest that key risk factors contributing to asthma morbidity within the inner city include social demography, the physical environment (indoor and outdoor), and health care access and quality. This epidemiologic literature has helped to define opportunities for successful intervention strategies in these high-risk populations. Studies of the effectiveness of community-based and health system-based interventions with specific focus on inner-city populations are beginning to emerge in the literature.

Assessing health in an urban neighborhood: community process, data results and implications for practice

This article examines the community process and data results of a health assessment conducted in an urban neighborhood of a middle-size city in Western Massachusetts. It describes the four-stage development process of the Health Assessment Project (HAP), a collaboration of the UMASS School of Public Health faculty and students, community based organizations and youth residents: (1) planning with a contemporary participatory approach, (2) implementing the data collection with traditional survey methodology, (3) tailoring the data analysis for a presentation at a community forum and report, and (4) incorporating the community's reaction to data results. In addition, it presents selected data results on health conditions of individual household members and perceived community health concerns and resources. Salient data results include high rates of chronic health conditions such as asthma and other respiratory problems among residents 0-18, back pain and other musculoskeletal among younger adults 19-54, and high blood pressure and other cardi-circulatory problems among older adults age 55 and older. The three most prevalent perceived community concerns are substance abuse, gangs and drug dealing. Identified community resources include sources of (1) providers of primary care, (2) health information as family/friends and Spanish media, (3) social activity such as churches and schools. Finally, this paper concludes by discussing implications for community health practice.

Race, income, urbanicity, and asthma hospitalization in California: a small area analysis

STUDY OBJECTIVES

To explicate the interrelationship between asthma hospitalization and race/ethnicity and income.

DESIGN

Small area ecologic analysis using census and administrative data.

SETTING AND PARTICIPANTS

All asthma hospitalizations in California were identified using the 1993 California Hospital Discharge file. Small area analyses of Los Angeles (LA) were compared with published rates in New York City (NYC).

RESULTS

In 1993, the age-adjusted asthma hospitalization rate in California for nonelderly blacks was 42.5/10,000-approximately four times higher than other populations. Black rates remained fourfold higher after stratification by age, income, and urbanicity. Multivariate analyses suggest that the association between black race and asthma hospitalization is independent of income. Regardless of race, children and persons living in poverty were at increased risk for asthma hospitalization. Urbanicity was not a predictor for asthma hospitalization. Overall, asthma hospitalization rates in NYC were 2.8 times higher compared with rates in LA; while rates were similar among blacks (60 vs 40/10,000, respectively), Puerto Rican Hispanics in NYC had dramatically higher rates compared with Mexican Hispanics in LA (63 vs 14/10,000, respectively).

CONCLUSIONS

After controlling for socioeconomic status, notable differences in asthma hospitalization by race and ethnicity persist. The reasons for the significantly elevated risk of asthma morbidity among blacks remain unclear.

Evaluation of a school-based asthma education program for inner-city children

BACKGROUND

We have previously reported a high prevalence of current asthma-related symptoms affecting predominantly Hispanic, socioeconomically disadvantaged schoolchildren in Southeast San Diego.

OBJECTIVE

We sought to assess the impact of a school-based education program on asthma outcomes.

METHODS

In cooperation with the San Diego Unified Schools, we developed and implemented a school-based asthma education program. Based on the National Heart, Lung, and Blood Institute consensus guidelines for asthma, the five-session bilingual, interactive curriculum was conducted in 20-minute segments. Asthma knowledge was tested before and after the education program, and asthma severity was prospectively assessed at monthly intervals. Outcome parameters were compared in educated and control (noneducated) fourth grade students with asthma by using nonparametric techniques.

RESULTS

After asthma education, students demonstrated improvement with increases in mean scores for: asthma knowledge quiz from 9.9 (SEM = 0.44, n = 34) to 13.7 (SEM = 0.30); peak flowmeter technique from 3.9 (SEM = 0.33, n = 32) to 6.4 (SEM = 0.29); and inhaler technique from 2.3 (SEM = 0.26, n = 32) to 4.3 (SEM = 0.26). All changes were highly significant (p < or = 0.00001 as determined by Wilcoxon matched-pairs signed-rank test). Mean score comparisons for asthmatic control students given paired examinations after a time interval matched with the educated students, did not reach statistical significance: quiz score of 11.3 (SEM = 0.80, n = 11) versus 10.9 (SEM = 0.68), peak flowmeter technique score of 2.6 (SEM = 0.50, n = 18) versus 3.1 (SEM = 0.37) , and inhaler technique score of 2.5 (SEM = 0.37, n = 18) versus 2.2 (SEM = 0.31). Prospective monthly data were collected on 27 educated and 15 control asthmatic subjects. Severity of asthma was not significantly different between groups at entry to the study. Symptom questionnaires, validated for functional asthma severity, revealed a significant reduction in mean symptom scores at 180 days for the educated (2.87, SEM = 0.447) versus the control (4.36, SEM = 0.573) groups (p = 0.0188 as determined by the Mann-Whitney U test).

CONCLUSION

Child-centered asthma education can be successfully conducted in the school setting, resulting in increased asthma knowledge, improved skills for peak flowmeter and inhaler use, and a reduction in the severity of asthma symptoms.

Exposure and sensitization to environmental allergen of predominantly Hispanic children with asthma in San Diego's inner city

BACKGROUND

Environmental living conditions co-sorting with economic status may influence the disease morbidity rate of childhood asthma in ethnic minority urban poor populations.

OBJECTIVES

This study was carried out to assess exposure and sensitization to environmental allergens in southeast San Diego children with current asthma-related symptoms and to determine the utility of environmental control measures.

METHODS

Children, 9 to 12 years old, with current asthma-related symptoms were identified and enrolled at four school sites. Skin prick testing with aeroallergens was performed, and allergen in collected dust (from mattresses, pillows, and bedroom carpets) was quantified by enzyme immunoassay. Environmental control instruction and products were provided.

RESULTS

Of 41 subjects who underwent skin testing, 51.2% were reactive to environmental allergens (39% to mite, 22% to cockroach, and 9.8% to cat). Mean allergen levels for sensitized subjects were: Der p 1 (11 subjects), 18,722 ng/gm dust; Der f 1 (8 subjects), 5345 ng/gm dust; Fel d 1 (3 subjects), 214 ng/gm dust; Bla 1 (8 subjects), 7.15 U/gm dust; and Bla 2 (8 subjects) 7.13 U/gm dust. Environmental allergen exposure levels were not significantly different between sensitized and nonsensitized subjects. Environmental control measures for mite exposure were completed in six homes of sensitized subjects. One month after treatment, allergen levels fell 91.2% for Der p 1, 98.9% for Der f 1, and 88.2% for Fel d 1. One year after treatment, mite and cat allergen levels remained low. Environmental control had no consistent impact on cockroach allergen levels.

CONCLUSION

Environmental allergen sensitization and exposure may be cofactors contributing to increased disease severity in urban poor populations.