Socioeconomic factors and asthma hospitalization rates in New York City

Effects of prenatal polycyclic aromatic hydrocarbons and childhood material hardship on reading achievement in school-age children: A preliminary study

Background

Children from socioeconomically disadvantaged backgrounds are at elevated risk for reading problems. They are also likely to live in neighborhoods with high levels of air pollution and to experience material hardship. Despite these risk factors, the links between prenatal chemical exposures, socioeconomic adversities, and reading problems in youth from disadvantaged backgrounds remain understudied. Here we examine associations between prenatal exposure to polycyclic aromatic hydrocarbons (PAH), a common air pollutant, and reading skills, and determine if this relationship is exacerbated by material hardship among Black and/or Latinx children who have been followed as part of a longitudinal urban birth cohort.

Methods

Mothers and their children, who were participants in a prospective birth cohort followed by the Columbia Center for Children's Environmental Health, were recruited for the current study. Personal prenatal PAH exposure was measured during the third-trimester of pregnancy using a personal air monitoring backpack. Mothers reported their level of material hardship when their child was age 5 and children completed measures of pseudoword and word reading [Woodcock Johnson III Tests of Achievement (WJ-III) Basic Reading Index] at age 7. We used multiple linear regression to examine the effects of the interaction between prenatal PAH and material hardship on Basic Reading Index, controlling for ethnicity/race, sex, birthweight, presence of a smoker in the home (prenatal), and maternal education (prenatal) (N = 53).

Results

A prenatal PAH × material hardship interaction significantly associated with WJ-III Basic Reading Index scores at age 7 (β = -0.347, t(44) = -2.197, p = 0.033). Exploratory analyses suggested that this effect was driven by untimed pseudoword decoding (WJ-III Word Attack: β = -0.391, t(44) = -2.550, p = 0.014).

Conclusion

Environmental chemical exposures can be particularly toxic during the prenatal period when the fetal brain undergoes rapid development, making it uniquely vulnerable to chemical perturbations. These data highlight the interactive effects of environmental neurotoxicants and unmet basic needs on children's acquisition of reading skill, specifically phonemic processing. Such findings identify potentially modifiable environmental risk factors implicated in reading problems in children from economically disadvantaged backgrounds.

Childhood Maltreatment, Blood Lead Levels, and Crime and Violence: A Prospective Examination

BACKGROUND

Research has shown that maltreated children are at increased risk for subsequent crime and violence and are more likely to reside in neighborhoods with a high likelihood of lead exposure. Other literature has reported associations between childhood lead exposure and antisocial and criminal behavior. Little is known about the relationships among childhood maltreatment, adult lead exposure, and crime and violence.

METHODS

As part of a prospective longitudinal study of the long-term consequences of childhood maltreatment, children with documented histories of abuse and neglect and demographically matched control children (ages 0-11 years) were followed into adulthood and interviewed. Participants included 556 individuals who had valid blood lead level (BLL) measures at a mean age of 41.2 years. Participants had a mean age of 50.5 (SD = 3.53) years at the time of the last criminal history check used to determine the number of arrests.

RESULTS

Childhood maltreatment predicted a higher number of arrests for any crime and any violence after the blood was collected but not higher BLLs in adulthood. There were significant paths from adult BLLs to arrests after the blood was collected, despite controlling for age, sex, race, and IQ and the inclusion of individual- and neighborhood-level socioeconomic status, and paths from neighborhood socioeconomic status to higher BLLs in models predicting any arrest and any violent arrest after the blood was collected.

CONCLUSIONS

These findings demonstrate how environmental toxins such as lead can affect outcomes in adulthood, including crime, and provide evidence that links neighborhood disadvantage to higher BLLs in adulthood.

Early childhood exposure to ambient air pollution is associated with increased risk of paediatric asthma: An administrative cohort study from Stockholm, Sweden

INTRODUCTION

Asthma is a complex, heterogeneous disease and one of the most common chronic diseases among children. Exposure to ambient air pollution in early life and childhood may influence asthma aetiology, but it is uncertain which specific components of air pollution and exposure windows are of importance. The role of socio-economic status (SES) is also unclear. The aims of the present study are, therefore, to investigate how various exposure windows of different pollutants affect risk-induced asthma in early life and to explore the possible effect SES has on that relationship.

METHODS

The study population was constructed using register data on all singleton births in the greater Stockholm area between 2006 and 2013. Exposure to ambient black carbon (BC), fine particulate matter (PM_2.5), primary organic carbon (pOC) secondary organic aerosols (SOA), secondary inorganic aerosols, and oxidative potential at the residential address was modelled as mean values for the entire pregnancy period, the first year of life and the first three years of life. Swedish national registers were used to define the outcome: asthma diagnosis assessed at hospital during the first six years of life. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were modelled with Cox proportional hazards model with age as the underlying time-scale, adjusting for relevant potential confounding variables.

RESULTS

An increased risk for developing childhood asthma was observed in association with exposure to PM_2.5, pOC and SOA during the first three years of life. With an interquartile range increase in exposure, the HRs were 1.06 (95% CI: 1.01-1.10), 1.05 (95% CI: 1.02-1.09) and 1.02 (95% CI: 1.00-1.04), for PM_2.5, pOC and SOA, respectively, in the fully adjusted models. Exposure during foetal life or the first year of life was not associated with asthma risk, and the other pollutants were not statistically significantly associated with increased risk. Furthermore, the increase in risk associated with PM_2.5 and the components BC, pOC and SOA were stronger in areas with lower SES.

CONCLUSION

Our results suggest that exposure to air pollution during the first three years of life may increase the risk for asthma in early childhood. The findings further imply a possible increased vulnerability to air pollution-attributed asthma among low SES children.

Childhood maltreatment and lead levels in middle adulthood: A prospective examination of the roles of individual socio-economic and neighborhood characteristics

BACKGROUND

Lead is a common environmental hazard because of its past use as an additive to gasoline and household paint. Some evidence suggests that children with histories of child abuse and neglect are at elevated risk for residence in communities and households with less desirable characteristics and high levels of exposure to environmental hazards and toxins.

OBJECTIVES

To understand whether childhood maltreatment leads to higher levels of household dust lead and blood lead in adulthood and the extent to which characteristics of a person's physical environment or individual level socio-economic status (SES) (based on unemployment, poverty, and receipt of public assistance) contribute to understanding the relationship.

METHODS

A large prospective cohort design study in which abused and neglected children (ages 0-11) were matched with non-maltreated children and assessed in adulthood. Objective and subjective neighborhood characteristics were assessed at approximate age 40 and household dust lead (cleaned and less often cleaned) and blood lead levels were measured at age 41. Blood was collected through venipuncture by a registered nurse as part of a medical status exam.

RESULTS

Childhood maltreatment predicted higher levels of dust lead in less often cleaned household places, residence in worse neighborhoods defined by objective (census tract data) and subjective (reports of physical disorder and lack of social cohesion and control), and higher levels of poverty, receiving public assistance, and unemployment. Only objective neighborhood characteristics mediated the relationship between childhood maltreatment and dust lead level in adulthood. There were also significant paths from objective neighborhood disadvantage and individual level SES to higher levels of blood lead.

DISCUSSION

Thirty years after their childhood experiences, individuals with documented histories of childhood maltreatment are at higher risk for living in environments as adults with elevated lead levels that may impact other aspects of their lives and compromise their health.

Association of In Utero HIV Exposure With Obesity and Reactive Airway Disease in HIV-Negative Adolescents and Young Adults

BACKGROUND

HIV-negative individuals with in utero HIV exposure represent an emerging population, exceeding 18 million people worldwide. Long-term clinical outcomes among HIV-exposed uninfected (HEU) individuals into adolescence and young adulthood remain unknown.

SETTING

US academic health system.

METHODS

In this observational cohort study, we leveraged a patient data registry to identify 50 HEU adolescents and young adults. We also identified 141 HIV-unexposed controls that were matched to HEU subjects up to 3:1 on age of last encounter (±2 years), birthdate (±5 years), sex, race/ethnicity, and zip code. All subjects were born since January 1, 1990, with medical records available into adolescence and young adulthood. Primary outcomes were most recent body mass index (BMI) z-score and presence of reactive airway disease (RAD). Records were manually reviewed to extract health information.

RESULTS

Fifty HEU adolescents and young adults (18 ± 3 years, 54% men) and 141 matched controls (19 ± 3 years, 54% men) were compared. HEU individuals had a higher BMI z-score (1.12 ± 1.08 vs. 0.73 ± 1.09, P = 0.03) and an increased prevalence of obesity (42% vs. 22%, P = 0.009) compared with controls. HEU subjects also had a higher prevalence of RAD vs. controls (40% vs. 23%, P = 0.03). These differences persisted on adjusting for demographic, socioeconomic, maternal, and birth-related factors. Maternal prenatal CD4 T-cell count was inversely associated with BMI z-score among HEU adolescents (r = -0.47, P = 0.01).

CONCLUSIONS

HEU adolescents and young adults exhibited a heightened prevalence of obesity and RAD compared with HIV-unexposed controls. Additional studies are needed to optimize care for the expanding population of HEU individuals transitioning to adulthood.

Prevalence and determinants of asthma among aboriginal adolescents in Canada

Objective: The objective of the study was to determine the prevalence and associated risk factors of asthma in Aboriginal adolescents in Canada based on the Canadian Aboriginal Peoples Survey (APS) 2012. Few studies have investigated the prevalence and risk factors of asthma in Aboriginal adolescents in Canada. Methods: Data from the cross-sectional APS 2012 were analyzed to accomplish the objective. Logistic regression analysis was utilized to determine significant risk factors of lifetime diagnosis of asthma among Aboriginal adolescents. The outcome of interest for adolescents was based on the question: "Do you have asthma that have been diagnosed by a health professional?" Individual, environmental, and contextual factors were tested for an association with lifetime diagnosis of asthma among adolescents. Results: The overall prevalence of lifetime diagnosis of asthma was 16.0%. The prevalence of lifetime diagnosis of asthma was 16.8% for adolescent boys and 15.3% for adolescent girls. Based on multivariable logistic regression analysis, the risk factors of lifetime diagnosis of asthma were: age, income, being overweight, smoking inside the home, having one to two children under 18 years in the household, history of bronchitis, living in an urban residence, education, and geographical location. Female sex was reported to have a protective effect on or reduce risk of the prevalence of lifetime diagnosis of asthma compared to the male sex. Conclusions: Lifetime diagnosis of asthma prevalence appears to be lower in Aboriginal adolescent girls than in adolescent boys. Lifetime diagnosis of asthma prevalence in these adolescents is associated with age, income, education, being overweight, smoking inside the home, history of bronchitis, and location of residence, both geographical region and urban residence. The prevalence of lifetime diagnosis of asthma among Aboriginal adolescent is higher compared to the general adolescent population in Canada.

The Use of Geographic Data to Improve Asthma Care Delivery and Population Health

The authors examine uses of geographic data to improve asthma care delivery and population health and describe potential practice changes and areas for future research.

Value of Neighborhood Socioeconomic Status in Predicting Risk of Outcomes in Studies That Use Electronic Health Record Data

IMPORTANCE

Data from electronic health records (EHRs) are increasingly used for risk prediction. However, EHRs do not reliably collect sociodemographic and neighborhood information, which has been shown to be associated with health. The added contribution of neighborhood socioeconomic status (nSES) in predicting health events is unknown and may help inform population-level risk reduction strategies.

OBJECTIVE

To quantify the association of nSES with adverse outcomes and the value of nSES in predicting the risk of adverse outcomes in EHR-based risk models.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study in which data from 90 097 patients 18 years or older in the Duke University Health System and Lincoln Community Health Center EHR from January 1, 2009, to December 31, 2015, with at least 1 health care encounter and residence in Durham County, North Carolina, in the year prior to the index date were linked with census tract data to quantify the association between nSES and the risk of adverse outcomes. Machine learning methods were used to develop risk models and determine how adding nSES to EHR data affects risk prediction. Neighborhood socioeconomic status was defined using the Agency for Healthcare Research and Quality SES index, a weighted measure of multiple indicators of neighborhood deprivation.

MAIN OUTCOMES AND MEASURES

Outcomes included use of health care services (emergency department and inpatient and outpatient encounters) and hospitalizations due to accidents, asthma, influenza, myocardial infarction, and stroke.

RESULTS

Among the 90 097 patients in the training set of the study (57 507 women and 32 590 men; mean [SD] age, 47.2 [17.7] years) and the 122 812 patients in the testing set of the study (75 517 women and 47 295 men; mean [SD] age, 46.2 [17.9] years), those living in neighborhoods with lower nSES had a shorter time to use of emergency department services and inpatient encounters, as well as a shorter time to hospitalizations due to accidents, asthma, influenza, myocardial infarction, and stroke. The predictive value of nSES varied by outcome of interest (C statistic ranged from 0.50 to 0.63). When added to EHR variables, nSES did not improve predictive performance for any health outcome.

CONCLUSIONS AND RELEVANCE

Social determinants of health, including nSES, are associated with the health of a patient. However, the results of this study suggest that information on nSES may not contribute much more to risk prediction above and beyond what is already provided by EHR data. Although this result does not mean that integrating social determinants of health into the EHR has no benefit, researchers may be able to use EHR data alone for population risk assessment.

Psychosocial Factors in Severe Pediatric Asthma

Asthma is the most common chronic illness among children in the United States and can impact nearly all aspects of functioning. Most research suggests that children with severe asthma display more emotional and behavioral problems than their healthy peers. These psychological difficulties are associated with increased risk for functional impairments and problematic disease course. Multidisciplinary teams that assess and treat these psychosocial factors using psychoeducational and behavioral interventions are important for children whose asthma is poorly controlled. Future research should examine the ways in which stress, emotions, and immune functions interact, so as to develop more preventative interventions.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

BACKGROUND

Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Children's Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years.

METHODS

Analysis of our institution's readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions.

RESULTS

From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions.

CONCLUSION

A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

Socioeconomic Disparities and Influenza Hospitalizations, Tennessee, USA

We examined population-based surveillance data from the Tennessee Emerging Infections Program to determine whether neighborhood socioeconomic status was associated with influenza hospitalization rates. Hospitalization data collected during October 2007-April 2014 were geocoded (N = 1,743) and linked to neighborhood socioeconomic data. We calculated age-standardized annual incidence rates, relative index of inequality, and concentration curves for socioeconomic variables. Influenza hospitalizations increased with increased percentages of persons who lived in poverty, had female-headed households, lived in crowded households, and lived in population-dense areas. Influenza hospitalizations decreased with increased percentages of persons who were college educated, were employed, and had health insurance. Higher incidence of influenza hospitalization was also associated with lower neighborhood socioeconomic status when data were stratified by race.

The Role of the Epigenome in Translating Neighborhood Disadvantage Into Health Disparities

The possible causal role of the environment in health disparities is not well understood, even though it has been a national priority for many years. Progress to investigate the relationship between genetics, environmental exposures, and health outcomes has been hampered by the lack of analytical tools to quantify the combined or cumulative effect of multiple chemical and non-chemical stressors on gene expression. The studies cited here provide a strong rationale for using epigenomic analysis to assess cumulative risk from multiple environmental exposures over the life course. The environment-specific "imprints" on the genome, coupled with transcriptomics and metabolomics, can be used to advance our understanding of the relationship between neighborhood disadvantage and health disparities.

Adjusting for geographic variation in observational comparative effectiveness studies: a case study of antipsychotics using state Medicaid data

Background

Area-level variation in treatment and outcomes may be a potential source of confounding bias in observational comparative effectiveness studies. This paper demonstrates how to use exploratory spatial data analysis (ESDA) and spatial statistical methods to investigate and control for these potential biases. The case presented compares the effectiveness of two antipsychotic treatment strategies: oral second-generation antipsychotics (SGAs) vs. long-acting paliperiodone palmitate (PP).

Methods

A new-start cohort study was conducted analyzing patient-level administrative claims data (8/1/2008–4/30/2011) from Missouri Medicaid. ESDA techniques were used to examine spatial patterns of antipsychotic prescriptions and outcomes (hospitalization and emergency department (ED) visits). Likelihood of mental health-related outcomes were compared between patients starting PP (N = 295) and oral SGAs (N = 8,626) using multilevel logistic regression models adjusting for patient composition (demographic and clinical factors) and geographic region.

Results

ESDA indicated significant spatial variation in antipsychotic prescription patterns and moderate variation in hospitalization and ED visits thereby indicating possible confounding by geography. In the multilevel models for this antipsychotic case example, patient composition represented a stronger source of confounding than geographic context.

Conclusion

Because geographic variation in health care delivery is ubiquitous, it could be a comparative effectiveness research (CER) best practice to test for possible geographic confounding in observational data. Though the magnitude of the area-level geography effects were small in this case, they were still statistically significant and should therefore be examined as part of this observational CER study. More research is needed to better estimate the range of confounding due to geography across different types of observational comparative effectiveness studies and healthcare utilization outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/1472-6963-14-355) contains supplementary material, which is available to authorized users.

Prenatal exposure to airborne polycyclic aromatic hydrocarbons and IQ: estimated benefit of pollution reduction

Outdoor air pollution, largely from fossil fuel burning, is a major cause of morbidity and mortality in the United States, costing billions of dollars every year in health care and loss of productivity. The developing fetus and young child are especially vulnerable to neurotoxicants, such as polycyclic aromatic hydrocarbons (PAH) released to ambient air by combustion of fossil fuel and other organic material. Low-income populations are disproportionately exposed to air pollution. On the basis of the results of a prospective cohort study in a low-income population in New York City (NYC) that found a significant inverse association between child IQ and prenatal exposure to airborne PAH, we estimated the increase in IQ and related lifetime earnings in a low-income urban population as a result of a hypothesized modest reduction of ambient PAH concentrations in NYC of 0.25 ng/m(3). For reference, the current estimated annual mean PAH concentration is ~1 ng/m(3). Restricting to NYC Medicaid births and using a 5 per cent discount rate, we estimated the gain in lifetime earnings due to IQ increase for a single year cohort to be US$215 million (best estimate). Using much more conservative assumptions, the estimate was $43 million. This analysis suggests that a modest reduction in ambient concentrations of PAH is associated with substantial economic benefits to children.

Qingfei Xiaoyan Wan alleviates asthma through multi-target network regulation

BACKGROUND

Qingfei Xiaoyan Wan (QFXY), a traditional Chinese formula, is widely used for relieving cough, asthma, upper respiratory tract infection, bronchitis, pneumonia, and etc. in clinic. Comparing with other anti-asthma drugs, it is characterised with moderate and persistent efficacy as well as few side effects, however, the underlying action mechanism still remains elusive. This study aimed to identify QFXY multi-target network regulation as an asthma controller.

METHODS

This study established asthma model induced by histamine phosphate and acetylcholine chloride (His&Ach) in guinea pigs, which then were administered orally with QFXY. Hematoxylin-Eosin staining sections were applied for evaluating QFXY effect. In both Model and QFXY groups, customized microarrays and 2D electrophoresis were adopted to detect differentially expressed genes (diff genes) and proteins (diff proteins) respectively, and some diff proteins were identified with MALDI-TOF/MS. The checked diff genes and proteins underwent Cluster, GO and KEGG analysis. Based on GAD and HPRD databases, QFXY-asthma target regulation network was constructed.

RESULTS

His&Ach-induced asthma model of guinea pigs was established. HE sections presented anti-inflammation and anti-remodelling effects of QFXY. Comparing with the Model group, 55 diff genes and 6 diff proteins were identified in QFXY group. Validation by qPCR and Western blot showed the microarray and 2D data reliable. Furthermore, QFXY-asthma target regulation network was achieved.

CONCLUSIONS

A primarily combined genomic and proteomic screening of QFXY targets displayed a series of candidate genes and proteins, which indicated that the effect of QFXY relied on the combined mechanism, anti-inflammation and anti-remodelling, as well as influencing signal transduction in vivo.

Computer-assisted school-based asthma management: a pilot study

Background

The high prevalence of asthma among children continues to be a major public health issue. In particular, low-income African-American and Hispanic children often receive asthma care in the emergency department and lack access to continuity of care.

Objective

The aim of the current study was to test the feasibility of implementing a computerized program for empowering low-income children with asthma to manage their own disease. This pilot program consisted of a guided, personalized, Web-based computer program as the main component of a school-based asthma intervention.

Methods

The Automated Live E-Health Response Tracking System (ALERTS), a computer-assisted, Web-based tracking program, was tested for implementation in a school in East Harlem, New York. The program required children with asthma, assisted by trained researchers, to routinely measure their peak flow meter readings and answer a symptom questionnaire. The program provided individualized feedback on their disease status based on peak flow meter input. The computer program sent reports to the child’s physician and the nurse practitioner at the on-site school health center. The children were also encouraged to bring the reports home to their parents. A pre/post study design was employed such that each participant acted as his/her own control. Comparisons of preintervention and postintervention outcomes were calculated using the paired t-test and the McNemar test for dichotomous data.

Results

Twenty-four children (6 to 12 years) participated in the program over 2 to 15 months. Improvements in health outcomes showed the greatest significance among the group of participants who were enrolled for 8 months or longer. Statistically significant improvements were seen in the average physical health score of the children (from 65.64 preintervention to 76.28 postintervention, P = .045). There was a significant decrease in the number of participants experiencing wheezing episodes (n = 9 to n = 2, P = .03), and in the average number of wheezing episodes per child (1.86 to 0.43, P = .02). Although not statistically significant, decreases were also seen in the number of children experiencing an asthma attack and in the average number of asthma attacks among participants. There was also a significant decrease in the average number of visits to doctors’ offices or clinics (1.23 to 0.38, P = .04). There were no overnight hospitalizations in the two-week period following the end of the pilot program, a nonsignificant reduction from an average of 0.21 per child.

Conclusion

This individualized, computer-assisted intervention resulted in improvements in some health outcomes among low-income children in an urban, public school-based setting. Consistent peak flow meter self-measurements, management of medication usage, and a computerized approach to symptom tracking resulted in fewer asthma exacerbations and improved overall physical health among this pediatric population with asthma.

Geomedicine: area-based socioeconomic measures for assessing risk of hospital reutilization among children admitted for asthma

OBJECTIVES

We assessed whether geographic information available at the time of asthma admission predicts time to reutilization (readmission or emergency department revisit).

METHODS

For a prospective cohort of children hospitalized with asthma in 2008 and 2009 in Cincinnati, Ohio, we constructed a geographic social risk index from geocoded home addresses linked to census tract extreme poverty and high school graduation rates and median home values. We examined geographic risk associations with reutilization and caregiver report of hardship.

RESULTS

Thirty-nine percent of patients reutilized within 12 months. Compared with those in the lowest geographic risk stratum, those at medium and high risk had 1.3 (95% confidence interval [CI] = 0.9, 1.9) and 1.8 (95% CI = 1.4, 2.4) the risk of reutilization, respectively. Caregivers of children at highest geographic risk were 5 times as likely to report more than 2 financial hardships (P < .001) and 3 times as likely to report psychological distress (P = .001).

CONCLUSIONS

A geographic social risk index may help identify asthmatic children likely to return to the hospital. Targeting social risk assessments and interventions through geographic information may help to improve outcomes and reduce disparities.

Relationships between deprivation and duration of children's emergency admissions for breathing difficulty, feverish illness and diarrhoea in North West England: an analysis of hospital episode statistics

BACKGROUND

In the United Kingdom there has been a long term pattern of increases in children's emergency admissions and a substantial increase in short stay unplanned admissions. The emergency admission rate (EAR) per thousand population for breathing difficulty, feverish illness and diarrhoea varies substantially between children living in different Primary Care Trusts (PCTs). However, there has been no examination of whether disadvantage is associated with short stay unplanned admissions at PCT-level. The aim of this study was to determine whether differences between emergency hospital admission rates for breathing difficulty, feverish illness and diarrhoea are associated with population-level measures of multiple deprivation and child well-being, and whether there is variation by length of stay and age.

METHODS

Analysis of hospital episode statistics and secondary analysis of Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-being (CWI) 2009 in ten adjacent PCTs in North West England. The outcome measure for each PCT was the emergency admission rate to hospital for breathing difficulty, feverish illness and diarrhoea.

RESULTS

23,496 children aged 0-14 were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2006/07. The emergency admission rate ranged from 27.9 to 62.7 per thousand. There were no statistically significant relationships between shorter (0 to 3 day) hospitalisations and the IMD or domains of the CWI. The rate for hospitalisations of 4 or more days was associated with the IMD (Kendall's tau(b) = 0.64) and domains of the CWI: Environment (tau(b) = 0.60); Crime (tau(b) = 0.56); Material (tau(b) = 0.51); Education (tau(b) = 0.51); and Children in Need (tau(b) = 0.51). This pattern was also evident in children aged under 1 year, who had the highest emergency admission rates. There were wide variations between the proportions of children discharged on the day of admission at different hospitals.

CONCLUSIONS

Differences between rates of the more common shorter (0 to 3 day) hospitalisations were not explained by deprivation or well-being measured at PCT-level. Indices of multiple deprivation and child well-being were only associated with rates of children's emergency admission for breathing difficulty, feverish illness and diarrhoea for hospitalisations of 4 or more days.

Social environment and asthma: associations with crime and No Child Left Behind programmes

BACKGROUND

The relationship between asthma and socio-economic status remains unclear. The authors investigated how neighbourhood, school and community social environments were associated with incident asthma in Southern California schoolchildren.

METHODS

New-onset asthma was measured over 3 years of follow-up in the Children's Health Study cohort. Multilevel random-effects models assessed associations between social environments and asthma, adjusted for individual risk factors. At baseline, subjects resided in 274 census tracts (ie, neighbourhoods) and attended kindergarten or first grade in one of 45 schools distributed in 13 communities throughout Southern California. Neighbourhoods and communities were characterised by measures of deprivation, income inequality and racial segregation. Communities were further described by crime rates. Information on schools included whether a school received funding related to the Title 1 No Child Left Behind programme, which aims to reduce academic underachievement in disadvantaged populations.

RESULTS

Increased risk for asthma was observed in subjects attending schools receiving Title I funds compared with those from schools without funding (adjusted HR 1.71, 95% CI 1.14 to 2.58), and residing in communities with higher rates of larceny crime (adjusted HR 2.02, 95% CI 1.08 to 3.02 across the range of 1827 incidents per 100,000 population).

CONCLUSIONS

Risk for asthma was higher in areas of low socio-economic status, possibly due to unmeasured risk factors or chronic stress.

The impact of socioeconomic factors on asthma hospitalization rates by rural classification

Asthma hospitalization rates have increased in the past decade. Research has shown that there are multiple correlates for this increase but that driving causal factors may differ for asthma hospitalization rates in rural and non-rural settings. Here we examine the socioeconomic correlates to asthma hospitalization rates in Maine for both rural and non-rural populations to examine the similarity and differences in causal factors. Findings indicate a clear SES gradient relative to asthma hospitalization rates; as population measured SES decreased, asthma hospitalization rates increased. The associated causal factors were found to differ in rural and non-rural areas. In non-rural areas, the presence of insurance was associated with increases in the asthma hospitalization rates while in rural areas, income, occupation and the percentage of non-English language speaking persons were associated with lower asthma hospitalization rates. Public policy should focus on targeted prevention strategies at the community level, especially in rural areas where cultural competency and socioeconomic factors are increasingly important.

Predictors of preventable hospitalization in chronic disease: priorities for change

Research in the area of preventable hospitalization, hospital admissions that could otherwise be avoided, provides little guidance in terms of priority areas for change. This synthesis of multiple electronic databases searched systematically for studies related to preventable hospitalization identifies six priority areas for future action in three broad conceptual areas: person priorities (symptom management and supportive relationships), programme priorities (self-management supports and service delivery), and place priorities (local infrastructure and socio-economic opportunities). Attention to these priorities could help reduce preventable hospitalization while simultaneously improving health access and quality of care.

Neighbourhood effects on hospitalization in early childhood

OBJECTIVE

To determine whether characteristics of neighbourhoods in which children live, such as socio-economic disadvantage, physical infrastructure, programs and services, social disconnection, smoking prevalence, and overcrowding, are related to hospitalization rates from birth to age six, independent of individual-level factors.

METHODS

We studied a population of 8,504 children born in Saskatoon, Canada, over a three-year period (1992-1994). The birth cohort was retrospectively followed until children reached age six. Birth registry records were linked to health care utilization files to create continuous histories of health care utilization for each child. Information on the neighbourhood in which the child's family resided at his or her birth was extracted from Statistics Canada's 1991 Census and numerous local sources. A longitudinal and multilevel design was employed to examine the effect of neighbourhood characteristics and individual-level factors on childhood hospitalization rate.

RESULTS

Male children, children born to mothers under 20 years of age, Aboriginal children, children in low-income families, and those with adverse birth outcomes had significantly higher rates of hospitalization. In addition to these individual factors, children living in economically disadvantaged neighbourhoods, neighbourhoods in poor physical condition, and neighbourhoods with higher average household size had significantly higher rates of hospitalization.

CONCLUSIONS

The kind of neighbourhood families live in has an impact on their children's risk of hospitalization, above and beyond the family's own characteristics. These findings provide additional support for a 'healthy community' approach that uses community development and healthy public policy to create safe, health-promoting neighbourhoods for all families.

Epidemiology of asthma: risk factors for development

This comprehensive review of the recent literature was undertaken to determine the current state of knowledge of the risk factors involved in the development of asthma in order to focus investigations in a proposed new longitudinal birth cohort study. The origins of asthma appear to lie in the prenatal and early postnatal period, and renewed investigations in this period with long-term close follow-up and objective phenotypic characterization will help to unravel the role of the multiple putative environmental factors in the development of asthma. It is only after understanding these effects that one can hope to design rational prevention studies for asthma.

Environmental justice and the health of children

Environmental injustice is the inequitable and disproportionately heavy exposure of poor, minority, and disenfranchised populations to toxic chemicals and other environmental hazards. Environmental injustice contributes to disparities in health status across populations of differing ethnicity, race, and socioeconomic status. Infants and children, because of their unique biological vulnerabilities and age-related patterns of exposure, are especially vulnerable to the health impacts of environmental injustice. These impacts are illustrated by sharp disparities across children of different racial and ethnic backgrounds in the prevalence of 3 common diseases caused in part by environmental factors: asthma, lead poisoning, and obesity. Documentation of linkages between health disparities and environmental injustice is an important step toward achieving environmental justice.

Residential smoking restrictions are not associated with reduced child SHS exposure in a baseline sample of low-income, urban African Americans

Second hand smoke exposure (SHSe) relates to many chronic and acute illnesses. Low income African American (AA) maternal smokers and their children have disproportionately higher tobacco-use and child SHSe-related morbidity and mortality than other populations. While public health officials promote residential smoking restrictions to reduce SHSe and promote smoking cessation, little is known about the impact of restrictions in changing smoking behavior and SHSe in this population. Thus, the purpose of this study was to examine associations between residential smoking restrictions, maternal smoking, and young children's SHSe in the context of other factors known to influence low income AA mothers' smoking behavior. For this study, we used cross-sectional, baseline data from 307 AA maternal smokers' pre-treatment interviews completed as part of a subsequent behavioral counseling trial to reduce their young (< 4 years old) children's SHSe. Residential smoking restriction was dichotomized as 0 = no restrictions and 1 = some restrictions. Child urine cotinine provided a biomarker of SHSe. Mothers reported cigarettes/day smoked, cigarettes/day exposed to child, and intention to quit. Multivariate regressions modeled effects of restriction as the primary predictor of smoking and exposure outcomes. Maternal smoking patterns such as cigarettes per day (β = 0.52, p < 0.001) and years smoked (β = -0.11; p = 0.03) along with presence of additional smokers in the home (β = 0.10; p = 0.04), but not residential restriction (β = -0.09, p = 0.10), predicted reported SHSe. Restriction did not relate to baby cotinine or maternal intention to quit. Thus, residential smoking restrictions may contribute to efforts to reduce children's SHSe and promote maternal smoking change; but alone, may not constitute a sufficient intervention to protect children. Multi-level intervention approaches that include SHSe-reduction residential smoking policies plus support and cessation assistance for smokers may be a necessary approach to smoke-free home adoption and adherence.

Factors associated with uncontrolled asthma in Porto Alegre, Brazil

The prevalence of uncontrolled and controlled asthma, and the factors associated with uncontrolled asthma were investigated in a cross-sectional study. Patients aged 11 years with confirmed asthma diagnosis were recruited from the outpatient asthma clinic of Hospital de Clínicas de Porto Alegre, Brazil. Patients were excluded if they had other chronic pulmonary disease. They underwent an evaluation by a general questionnaire, an asthma control questionnaire (based on the 2006 Global Initiative for Asthma guidelines), assessment of inhaled device technique and pulmonary function tests. Asthma was controlled in 48 of 275 patients (17.5%), partly controlled in 74 (26.9%) and uncontrolled in 153 (55.6%). In the univariate analysis, asthma severity was associated with asthma control (P < 0.001). Availability of asthma medications was associated with asthma control (P = 0.01), so that most patients who could purchase medications had controlled asthma, while patients who depend on the public health system for access to medications had lower rates of controlled asthma. The use of inhaled corticosteroid was lower in the uncontrolled group (P < 0.001). Logistic regression analysis identified three factors associated with uncontrolled asthma: severity of asthma (OR = 5.33, P < 0.0001), access to medications (OR = 1.97, P = 0.025) and use of inhaled corticosteroids (OR = 0.17, P = 0.030). This study showed a high rate of uncontrolled asthma in patients who attended an outpatient asthma clinic. Severity of asthma, access to medications and adequate use of inhaled corticosteroids were associated with the degree of asthma control.

Association between obesity and asthma in US children and adolescents

BACKGROUND

To explore the association between obesity and asthma in US children and adolescents with adjustment of other structural and behavioral factors.

METHOD

Prevalence and associated risk factors of asthma were explored in 102,273 children and adolescents in the National Survey of Children's Health (2003-2004). Subgroup analysis was performed for subjects of 0-6 year-old, 7-12 year-old, and 13-17 year-old. Crude and adjusted odds ratios for the potential risk factors were examined in univariate and multivariate logistic regressions.

RESULTS

The overall prevalence of obesity was 24.5% and that of asthma was 12.5%. The adjusted odds ratio of asthma with obesity remains significantly bigger than 1 for children in the 7-12 and the 13-17 year-old age-groups. Gender and race were significantly associated with asthma in all age groups. The two parent family structure showed significant protectiveness against asthma with children in the 0-6 year-old age group. Poverty was positively associated with asthma in the 7-12 years old age group. Having a smoker in the household increased the odds of asthma by 29% and 23.5% in the 0-6 and 13-17 year-old age-groups, respectively. Higher education level of the parents and access to healthcare showed positive association with asthma in the 13-17 year-old age group.

CONCLUSION

Gender and race were significantly associated with asthma. In the 13-17 year-old age-groups, obesity, household education level, healthcare coverage, and household smoking were positively associated with asthma. Further studies should characterize how the family structure and household education level influence childhood asthma in 0-6 and 13-17 year-old age-groups respectively.

Issues and methods in disparities research: the Rhode Island-Puerto Rico asthma center

BACKGROUND

Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research.

OBJECTIVES AND METHODS

This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island-Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research.

RESULTS

Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented.

CONCLUSIONS

Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them.

Prenatal airborne polycyclic aromatic hydrocarbon exposure and child IQ at age 5 years

OBJECTIVE

This study evaluated the relationship between prenatal exposure to airborne polycyclic aromatic hydrocarbons (PAHs) and child intelligence.

METHODS

Children of nonsmoking black or Dominican-American women residing in New York City were monitored from in utero to 5 years of age, with determination of prenatal PAH exposure through personal air monitoring for the mothers during pregnancy. At 5 years of age, intelligence was assessed for 249 children by using the Wechsler Preschool and Primary Scale of Intelligence-Revised. Multivariate linear regression models were used to estimate and to test the associations between prenatal PAH exposure and IQ.

RESULTS

After adjustment for maternal intelligence, quality of the home caretaking environment, environmental tobacco smoke exposure, and other potentially confounding factors, high PAH levels (above the median of 2.26 ng/m(3)) were inversely associated with full-scale IQ (P = .007) and verbal IQ (P = .003) scores. Children in the high-exposure group had full-scale and verbal IQ scores that were 4.31 and 4.67 points lower, respectively, than those of less-exposed children (

CONCLUSION

These results provide evidence that environmental PAHs at levels encountered in New York City air can affect children's IQ adversely.

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Key Words

• prenatal
• fetal
• polycyclic aromatic hydrocarbons
• air pollution
• iq

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MESH Headings

• Air Pollutants/toxicity
• Black People/psychology
• Child, Preschool
• Dominican Republic/ethnology
• Female
• Follow-Up Studies
• Hispanic or Latino/psychology
• Humans
• Infant
• Infant, Newborn
• Intelligence/drug effects
• New York City
• Polycyclic Aromatic Hydrocarbons/toxicity
• Pregnancy
• Prenatal Exposure Delayed Effects/psychology
• Urban Population
• Wechsler Scales
• Black or African American

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Grants

• RR00645 NCRR NIH HHS
• R01 ES012468 NIEHS NIH HHS
• R01ES012468 NIEHS NIH HHS
• R01 ES011158 NIEHS NIH HHS
• ES09089 NIEHS NIH HHS
• R01 ES008977 NIEHS NIH HHS
• 5R01ES08977 NIEHS NIH HHS
• R01 ES008977-12 NIEHS NIH HHS
• P01 ES009600-11 NIEHS NIH HHS
• R01 ES012468-03 NIEHS NIH HHS
• R01 DA027100 NIDA NIH HHS
• 5P01ES09600 NIEHS NIH HHS
• P30 ES009089 NIEHS NIH HHS
• R01ES111158 NIEHS NIH HHS
• P01 ES009600 NIEHS NIH HHS
• M01 RR000645 NCRR NIH HHS
• R01 ES011158-03 NIEHS NIH HHS

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Affiliation(s)

Frederica P Perera Department of Environmental Health Sciences, Columbia Center for Children's Environmental Healt, Mailman School of Public Health, Columbia University, New York, New York 10032, USA.
Zhigang Li
Robin Whyatt
Lori Hoepner
Shuang Wang
David Camann
Virginia Rauh

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Addressing asthma health disparities: a multilevel challenge

Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups.

Association between skin testing in the pediatric emergency department and adherence to follow-up in children with asthma

BACKGROUND

Efforts to enroll inner-city asthmatic children into continuity care after a pediatric emergency department (PED) visit are frequently unsuccessful. Providing parents with documentation of their child's allergic status and how this can be used to tailor an asthma management plan may improve adherence to scheduled continuity appointments.

OBJECTIVE

To determine whether skin testing children during PED visits for wheezing and providing parents with skin test results improves adherence to follow-up visits.

METHODS

A convenience sample of children aged 2 to 12 years with asthma who presented to the PED with wheezing were eligible. Enrolled children were randomized to group 1 (no skin test) or group 2 (skin test). At discharge, both groups scheduled asthma clinic appointments for within 1 week. Children in group 2 underwent skin testing with standard allergens, and parents were given documentation of skin test results. Adherence was assessed by computer confirmation of the patient's asthma clinic visit.

RESULTS

Seventy-seven children were enrolled: 39 in group 1 and 38 in group 2. The mean age was 7 years; 69% had mild intermittent asthma. Twenty-four percent of children (9 of 38) in group 1 vs 46% (17 of 37) in group 2 were followed up in the asthma clinic (P < .05). Children in group 2 were 2.6 (95% confidence interval, 1.02-6.65) times more likely to keep appointments compared with children in group 1.

CONCLUSIONS

Parents who receive evidence in the PED of their child's allergic status and probable relationship to the child's asthma are more likely to adhere to scheduled continuity visits.

Loose-coupling an air dispersion model and a geographic information system (GIS) for studying air pollution and asthma in the Bronx, New York City

This study developed new procedures to loosely integrate an air dispersion model, AERMOD, and a geographic information system (GIS) package, ArcGIS, to simulate air dispersion from stationary sources in the Bronx, New York City, for five pollutants: PM(10), PM(2.5), NO(x), CO, and SO(2). Plume buffers created from the model results were used as proxies of human exposure to the pollution from the sources and they modified the commonly used fixed-distance proximity buffers by considering the realities of air dispersion. The application of the plume buffers confirmed that the higher asthma hospitalization rates were associated with the higher potential exposure to local air pollution. The air dispersion modeling exhibited advantages over proximity analysis and geostatistical methods for environmental health research. The loose integration provides a relatively simple and feasible method for health scientists to take advantage of both air dispersion modeling and GIS by avoiding the need for intensive programming and substantial GIS expertise.

Hospital readmissions for childhood asthma: the role of individual and neighborhood factors

OBJECTIVES

This study used a Cox proportional hazards model to determine whether neighborhood characteristics are associated with risk of readmission for childhood asthma independently of individual characteristics.

METHODS

Rhode Island Hospital Discharge Data from 2001 to 2005 were used to identify children younger than 19 years of age at the time of the index (i.e., first) asthma admission, defined as a primary diagnosis of asthma or a primary diagnosis of respiratory illness with a secondary or tertiary diagnosis of asthma (n=2,919). Hazard ratios of repeat hospitalizations for childhood asthma from 2001 to 2005 were estimated, controlling for individual- and neighborhood-level variables.

RESULTS

During the study period, 15% of the sample was readmitted for asthma (n=451). In the unadjusted cumulative hazard curves, children residing in the census tracts with the highest proportion of crowded housing conditions, racial minority residents, or neighborhood-level poverty had higher cumulative hospital readmission rates as compared with children who resided in less disadvantaged neighborhoods. In the fully adjusted models, children insured by Medicaid at the time of their index admission had readmission rates that were 33% higher than children who were privately insured.

CONCLUSION

Our findings suggest that differences in health-care coverage are associated with higher readmission rates for pediatric asthma, but the relationship between neighborhood inequality and repeat hospitalizations for pediatric asthma requires further exploration. Social indicators such as minority race, Medicaid health insurance, and neighborhood markers of economic disadvantage are tightly interwoven in the U.S. and teasing these relationships apart is important in asthma disparities research.

Longitudinal patterns of predominant asthma disease activity in pediatric patients enrolled in an asthma-specific disease management program

To determine if patterns of predominant asthma disease activity are more closely related than baseline asthma severity to measures of morbidity (acute asthma attack, emergency room visit/hospitalization, missed school days, and/or steroid burst). Retrospective analysis was performed for inner-city Los Angeles asthmatic children (3 to 18 years of age) during their first year of enrollment in an asthma-specific disease management program. All measures of morbidity were more closely related to patterns of predominant disease activity than baseline severity. We conclude that patterns of predominant disease activity are a more significant predictor of asthma morbidity than is baseline severity.

Improving sampling and response rates in children's health research through participatory methods

BACKGROUND

Children's health is an important indicator of community health because children are especially vulnerable to disease. The school setting is ideal for assessing these vulnerabilities and prevalence of disease, yet the methods that produce high participation among students and their families are not usually described or evaluated. This is important because high participation rates increase reliability of data and interpretation of results.

METHODS

In order to determine which methods produce the highest response rates in a parent-report school-based survey, a child-focused protocol, consisting of a brief classroom presentation and incentives for participation, was compared to a parent/teacher outreach method and a teacher-only outreach protocol. Methods were implemented in schools matched on student demographics and neighborhood socioeconomic level. The child-focused method was found to yield the highest response rate; thus, it was deployed in 26 schools to determine its effectiveness in schools of varying socioeconomic levels.

RESULTS

Response rates were highest using the child-focused protocol when compared to those resulting from the parent/teacher outreach or the teacher-only protocols (80.5% vs 74.7%, 83.4% vs 45.8%, respectively). After full deployment, the response rate of the child-focused protocol was 76.9% (70.8-82.8%), with 46.9% of classrooms achieving a response rate of 80% or greater. The sample obtained was highly representative in racial/ethnic distribution, as evidenced by its strong correlation with the individual school enrollment, the 5- to 12-year-old population of surrounding ZIP codes, and the New York City public school population.

CONCLUSION

Participatory research methods that engage schoolchildren and school staff directly in the research process yield the highest response rates for school-based studies and provide educational benefits for the school community.

Factors associated with severe disease in a population of asthmatic children of Bogota, Colombia

BACKGROUND

There is evidence that prevalence and severity of asthma in children has risen. Risk factors for severe asthma have been studied extensively in children living in developed countries, but little is known about factors determining the severity of asthma in Latin American countries. The aim of this study was to investigate the role of suspected, potential risk factors for asthma severity in a population of children living in urban Bogota.

METHODS

We studied 175 children, 2 to 16 years old, with asthma attending an asthma clinic. Severe cases and nonsevere asthmatic subjects were compared regarding suspected, potential pre-, peri-, and postnatal risk factors.

RESULTS

After controlling for asthma duration, we found that children never breast fed (OR, 11.53; 95% CI, 2.35-56.50; p = 0.003), mothers 30 years or younger at the child's birth (OR, 3.44; 95% CI, 1.23-9.63; p = 0.019), usual use of acetaminophen for fever in the child in the 12 months previous to the survey application (OR, 3.13; 95% CI, 1.14-8.56; p = 0.026), older siblings at birth (OR, 3.81; 95% CI, 1.28-11.32; p = 0.016), and primary or secondary school as the highest level of education attained by mother (OR, 3.20; 95% CI, 1.01-10.07; p = 0.046) were all independent predictors of severe asthma.

CONCLUSION

No breastfeeding, maternal age at child's birth of less than 30 years, routine use of acetaminophen for fever in the child in the 12 months previous to the survey application, older siblings at birth, and primary or secondary school as the highest level of education attained by mother were independent predictors of severe asthma. Some of these risk factors are clearly modifiable. Further prospective, population-based studies with a bigger sample size and a more representative sample of the general population residing in the city are needed to retest and clarify these associations.

Household conditions, eczema symptoms and rhinitis symptoms: relationship with wheeze and severe wheeze in children living in the Polokwane area, South Africa

BACKGROUND

This is the fifth study that applied the International Study of Asthma and Allergies in Childhood (ISAAC) methodology in the Southern African Development Community (SADC region). However, it is the first ISAAC study that focused on 6- to 7-year-old children living in South Africa and that also investigated the association between potential risk factors and asthma symptoms. Objective To assess the 12-month prevalence of wheeze and severe wheeze along with their potential risk factors. Setting Within a 60-km radius from the Polokwane city centre, Limpopo Province.

METHODS

The survey was conducted during August 2004 and February 2005. Parents/guardians of 6- to 7-year-old children completed the questionnaires in English, Afrikaans or North-Sotho. However, the statistical analyses were restricted to the North-Sotho group (n = 2,437).

RESULTS

The 12-month prevalence rates of wheeze and severe wheeze were 11.2% and 5.7%, respectively. The 12-month prevalence rates of eczema symptoms and rhinoconjunctivitis symptoms were 8.0% and 7.3%, respectively. Living in a rural area significantly decreased the likelihood of wheeze by 31%. Exposure to environmental tobacco smoke at home and the presence of eczema symptoms and rhinoconjunctivitis symptoms increased the likelihood of wheeze by 77%, 104% and 226%, respectively. Only the presence of rhinoconjunctivitis symptoms increased the likelihood of severe wheeze by 107%.

CONCLUSION

Wheeze appears to be an emerging public health problem in the Polokwane area. Hopefully, detailed analytical intervention studies will further explicate these results in the near future.

Eliminating asthma disparities: a national workshop to set a working agenda

In February 2005, a national workshop was held in Chicago, IL, to address the problem of disparities in asthma. A multidisciplinary group of > 1,000 national experts reviewed key issues related to asthma health disparities; considered current research, clinical care, and policy related to this problem; and developed a set of recommendations to reduce these disparities. The themes addressed were genetics, indoor environment, outdoor environment, family/social function, behavioral health, health-care delivery, health-care communications, role of community, role of private insurance, role of safety net providers, and state and local policy.

Eliminating asthma disparities: introduction to the Chicago story

The problem of inner-city asthma, as studied in Chicago, IL, is introduced. Chicago has a high incidence of asthma, but prevalence, morbidity, and mortality rates vary by neighborhood and are highest in neighborhoods with the lowest socioeconomic status. Efforts in Chicago to mitigate these gaps have been extraordinary, but data suggest that there are challenges to improvement in removing disparities.

The role of economic and educational factors in asthma: evidence from the Portuguese health survey

OBJECTIVE

To evaluate the importance of economic and educational factors in determining the risk of asthma in adults.

STUDY DESIGN AND METHODS

This was a cross-sectional study in a representative sample of Portuguese adults (20,977 females and 18,663 males) from the main regions of mainland Portugal. Participants were categorized according to years of education (< or = 4, 5-9, 10-12 and >12 years) and income (< or = 314, 315-547, 548-815 and >815Euros/month). Information on asthma was based on answers to the following question: 'Have you had asthma in the previous year?' Logistic regression models were fitted to estimate the magnitude of the association between asthma and education/income, adjusting for confounders (body mass index, age, smoking habits, physical activity, area of residence, number of household members and income/education).

RESULTS

In females and males, the odds of having asthma decreased with increasing income (P-value for trend <0.001), with odds ratios of 0.52 [95% confidence intervals (CI) 0.41-0.66] and 0.55 (95%CI 0.44-0.68) for those with a monthly income >815 Euros compared with those with a monthly income 314 Euros, respectively. For both genders, the odds of having asthma were not significantly associated with years of education.

CONCLUSION

A significant positive association between per capita national income and asthma reinforces that public policy should stress the importance of economic growth as a means for preventing asthma occurrence and improving quality of life.

Variation in adult asthma prevalence in Hispanic subpopulations in New York City

BACKGROUND

We compared asthma prevalence among New York City Hispanics-Puerto Rican, Dominican, and other Hispanics-in relation to nativity, socioeconomic status, and asthma risk factors.

METHODS

Weighted logistic regression analyses on telephone survey data for New York City (NYC) adults in 2003/2004.

RESULTS

Asthma prevalence was highest among Puerto Ricans (11.8%) compared with Dominicans and other Hispanics. Non-US-born Dominicans and other Hispanics were significantly less likely to report current asthma than were Puerto Ricans (OR = 0.27, 95% CI 0.18-0.41 and OR = 0.17, 95% CI 0.11-0.26, respectively). In multivariate analyses, US-born Dominicans and other Hispanics had rates comparable to Puerto Ricans.

CONCLUSIONS

Puerto Ricans, both mainland- and native-born, report the highest rates of adult asthma. Non-US-born Hispanics report lower rates. Acculturation and patterns of residential settlement may account for this variation.

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.

Understanding disparities in asthma outcomes among African Americans

Racial disparities in asthma morbidity and mortality are greater than differences in asthma prevalence. This finding suggests that following the diagnosis of asthma, blacks receive substantially different care than non-Hispanic whites, through available health care systems and their social support networks, and racial differences in relevant environ-mental exposures contribute to differences in morbidity and mortality. An overview of factors that may contribute to disparities in asthma prevalence, morbidity, and mortality,including contextual factors, is provided.

Disparities in the use of urgent health care services among asthmatic children

BACKGROUND

Urgent care composes one third of the total costs associated with asthma. Asthmatic children of African American and Latino backgrounds have higher rates of emergency department (ED) use and hospitalizations than white children, especially in urban settings.

OBJECTIVE

To evaluate the role of socioeconomic, disease-related, and access-to-care factors in utilization of the ED and inpatient services for urgent treatment of asthma.

METHODS

A parent-response questionnaire was systematically distributed in public elementary schools that serve children of different socioeconomic backgrounds in New York City.

RESULTS

The prevalence of current asthma was found to be 13.0% in 5- to 12-year-old children. Almost half of the current asthmatic patients had used urgent care in the ED or hospital in the previous 12 months. In univariate analysis, use of urgent care was strongly associated with race/ethnicity and income (P < .001). Adjusting for socioeconomic, disease-related, and access-to-care factors, including household income, symptom severity, type of health insurance, and usual source of asthma care, the racial/ethnic disparity persisted, with Latinos having 5 times the risk and African Americans having double the risk of using urgent care as whites.

CONCLUSIONS

There is a failure in asthma management in this urban population, demonstrated by the finding that almost half of all current asthmatic patients used urgent care. After controlling for different socioeconomic and disease-related factors, minority race/ethnicity, low household income, and frequent evening symptoms were found to be strong predictors of urgent care utilization. Insurance status, delaying care for any reason, and use of controller medications were found not to be associated with urgent care use.

Asthma disparities in the prevalence, morbidity, and treatment of Latino children

The paper reviews the existing research related to asthma disparities and frames the results of this research within a conceptual model modified from the Institute of Medicine model in order to explain asthma health disparities in Latino children in the USA. The model of pediatric asthma disparity presented is based on the conceptualization of health disparities as the result of a complex interaction of factors related to four main domains: the individual and family, the environment or context in which the child lives, the health-care system, and provider characteristics. Asthma disparities are discussed as they are reflected in the process of care (access and quality of treatment) and outcome (prevalence, morbidity, severity) experienced by Latino children. The potential mechanisms that may account for the asthma disparities documented as reflected by the conceptual model proposed are discussed. Finally, several suggestions for future research examining determinants that account for asthma disparities are examined.

Asthma and enrollment in special education among urban schoolchildren

OBJECTIVES

We assessed whether asthma is associated with urban children's use of special education services.

METHODS

We conducted a cross-sectional study in 24 randomly selected New York City public elementary schools using a parent-report questionnaire focusing on sociodemographic characteristics, special education enrollment, asthma diagnosis and symptoms, school absences, and use of health care services.

RESULTS

Thirty-four percent of children enrolled in special education had been diagnosed with asthma, compared with 19% of children in the general student population. After control for sociodemographic factors, children with asthma were 60% more likely than children without asthma to be enrolled in special education (odds ratio [OR] = 1.62; 95% confidence interval [CI] = 1.22, 2.16). Asthmatic children in special education were significantly more likely to be from low-income families and to have been hospitalized in the previous 12 months than asthmatic children in general education.

CONCLUSIONS

Inadequate asthma control may contribute to a greater risk of asthmatic children residing in urban areas being placed in special education. School health programs should consider targeting low-income urban children with asthma at risk for enrollment in special education through increased asthma interventions and medical support services.