Measuring social determinants of health in the All of Us Research Program

To accelerate medical breakthroughs, the All of Us Research Program aims to collect data from over one million participants. This report outlines processes used to construct the All of Us Social Determinants of Health (SDOH) survey and presents the psychometric characteristics of SDOH survey measures in All of Us. A consensus process was used to select SDOH measures, prioritizing concepts validated in diverse populations and other national cohort surveys. Survey item non-response was calculated, and Cronbach's alpha was used to analyze psychometric properties of scales. Multivariable logistic regression models were used to examine associations between demographic categories and item non-response. Twenty-nine percent (N = 117,783) of eligible All of Us participants submitted SDOH survey data for these analyses. Most scales had less than 5% incalculable scores due to item non-response. Patterns of item non-response were seen by racial identity, educational attainment, income level, survey language, and age. Internal consistency reliability was greater than 0.80 for almost all scales and most demographic groups. The SDOH survey demonstrated good to excellent reliability across several measures and within multiple populations underrepresented in biomedical research. Bias due to survey non-response and item non-response will be monitored and addressed as the survey is fielded more completely.

Neighborhood Opportunity and Vulnerability and Incident Asthma Among Children

Background

The extent to which physical and social attributes of neighborhoods play a role in childhood asthma remains understudied.

Objective

To examine associations of neighborhood-level opportunity and social vulnerability measures with childhood asthma incidence.

Design, Setting, and Participants

This cohort study used data from children in 46 cohorts participating in the Environmental Influences on Child Health Outcomes (ECHO) Program between January 1, 1995, and August 31, 2022. Participant inclusion required at least 1 geocoded residential address from birth and parent or caregiver report of a physician's diagnosis of asthma. Participants were followed up to the date of asthma diagnosis, date of last visit or loss to follow-up, or age 20 years.

Exposures

Census tract-level Child Opportunity Index (COI) and Social Vulnerability Index (SVI) at birth, infancy, or early childhood, grouped into very low (<20th percentile), low (20th to <40th percentile), moderate (40th to <60th percentile), high (60th to <80th percentile), or very high (≥80th percentile) COI or SVI.

Main Outcomes and Measures

The main outcome was parent or caregiver report of a physician's diagnosis of childhood asthma (yes or no). Poisson regression models estimated asthma incidence rate ratios (IRRs) associated with COI and SVI scores at each life stage.

Results

The study included 10 516 children (median age at follow-up, 9.1 years [IQR, 7.0-11.6 years]; 52.2% male), of whom 20.6% lived in neighborhoods with very high COI and very low SVI. The overall asthma incidence rate was 23.3 cases per 1000 child-years (median age at asthma diagnosis, 6.6 years [IQR, 4.1-9.9 years]). High and very high (vs very low) COI at birth, infancy, or early childhood were associated with lower subsequent asthma incidence independent of sociodemographic characteristics, parental asthma history, and parity. For example, compared with very low COI, the adjusted IRR for asthma was 0.87 (95% CI, 0.75-1.00) for high COI at birth and 0.83 (95% CI, 0.71-0.98) for very high COI at birth. These associations appeared to be attributable to the health and environmental and the social and economic domains of the COI. The SVI during early life was not significantly associated with asthma incidence. For example, compared with a very high SVI, the adjusted IRR for asthma was 0.88 (95% CI, 0.75-1.02) for low SVI at birth and 0.89 (95% CI, 0.76-1.03) for very low SVI at birth.

Conclusions

In this cohort study, high and very high neighborhood opportunity during early life compared with very low neighborhood opportunity were associated with lower childhood asthma incidence. These findings suggest the need for future studies examining whether investing in health and environmental or social and economic resources in early life would promote health equity in pediatric asthma.

Impact of Spirometry Race-Correction on Preadolescent Black and White Children

BACKGROUND

Race-correction for Black patients is standard practice in spirometry testing. History suggests that these corrections are at least partially a result of racist assumptions regarding lung anatomy among Black individuals, which can potentially lead to less frequent diagnoses of pulmonary diseases in this population.

OBJECTIVE

To evaluate the impact of race-correction in spirometry testing among Black and White preadolescents, and examine the frequency of current asthma symptoms in Black children who were differentially classified depending on whether race-corrected or race-uncorrected reference equations were deployed.

METHODS

Data from Black and White children who completed a clinical examination at age 10 years from a Detroit-based unselected birth cohort were analyzed. Global Lung Initiative 2012 reference equations were applied to spirometry data using both race-corrected and race-uncorrected (ie, population-average) equations. Abnormal results were defined as values less than the fifth percentile. Asthma symptoms were assessed concurrently using the International Study of Asthma and Allergies in Childhood questionnaire, while asthma control was assessed using the Asthma Control Test.

RESULTS

The impact of race-correction on forced expiratory volume in 1 second (FEV1)/forced vital capacity ratio was minimal, but abnormal classification of FEV1 results more than doubled among Black children when race-uncorrected equations were used (7% vs 18.1%) and were almost 8 times greater based on forced vital capacity classification (1.5% vs 11.4%). More than half of Black children differentially classified on FEV1 (whose FEV1 was classified as normal with race-corrected equations but abnormal with race-uncorrected equations) experienced asthma symptoms in the past 12 months (52.6%), which was significantly higher than the percentage of Black children consistently classified as normal (35.5%, P = .049), but similar to that of Black children consistently classified as abnormal using both race-corrected and race-uncorrected equations (62.5%, P = .60). Asthma Control Test scores were not different based on classification.

CONCLUSIONS

Race-correction had an extensive impact on spirometry classification in Black children, and differentially classified children had a higher rate of asthma symptoms than children consistently classified as normal. Spirometry reference equations should be reevaluated to be aligned with current scientific perspectives on the use of race in medicine.

Associations of Neighborhood Opportunity and Social Vulnerability With Trajectories of Childhood Body Mass Index and Obesity Among US Children

Importance

Physical and social neighborhood attributes may have implications for children's growth and development patterns. The extent to which these attributes are associated with body mass index (BMI) trajectories and obesity risk from childhood to adolescence remains understudied.

Objective

To examine associations of neighborhood-level measures of opportunity and social vulnerability with trajectories of BMI and obesity risk from birth to adolescence.

Design, Setting, and Participants

This cohort study used data from 54 cohorts (20 677 children) participating in the Environmental Influences on Child Health Outcomes (ECHO) program from January 1, 1995, to January 1, 2022. Participant inclusion required at least 1 geocoded residential address and anthropometric measure (taken at the same time or after the address date) from birth through adolescence. Data were analyzed from February 1 to June 30, 2022.

Exposures

Census tract-level Child Opportunity Index (COI) and Social Vulnerability Index (SVI) linked to geocoded residential addresses at birth and in infancy (age range, 0.5-1.5 years), early childhood (age range, 2.0-4.8 years), and mid-childhood (age range, 5.0-9.8 years).

Main Outcomes and Measures

BMI (calculated as weight in kilograms divided by length [if aged <2 years] or height in meters squared) and obesity (age- and sex-specific BMI ≥95th percentile). Based on nationwide distributions of the COI and SVI, Census tract rankings were grouped into 5 categories: very low (<20th percentile), low (20th percentile to <40th percentile), moderate (40th percentile to <60th percentile), high (60th percentile to <80th percentile), or very high (≥80th percentile) opportunity (COI) or vulnerability (SVI).

Results

Among 20 677 children, 10 747 (52.0%) were male; 12 463 of 20 105 (62.0%) were White, and 16 036 of 20 333 (78.9%) were non-Hispanic. (Some data for race and ethnicity were missing.) Overall, 29.9% of children in the ECHO program resided in areas with the most advantageous characteristics. For example, at birth, 26.7% of children lived in areas with very high COI, and 25.3% lived in areas with very low SVI; in mid-childhood, 30.6% lived in areas with very high COI and 28.4% lived in areas with very low SVI. Linear mixed-effects models revealed that at every life stage, children who resided in areas with higher COI (vs very low COI) had lower mean BMI trajectories and lower risk of obesity from childhood to adolescence, independent of family sociodemographic and prenatal characteristics. For example, among children with obesity at age 10 years, the risk ratio was 0.21 (95% CI, 0.12-0.34) for very high COI at birth, 0.31 (95% CI, 0.20-0.51) for high COI at birth, 0.46 (95% CI, 0.28-0.74) for moderate COI at birth, and 0.53 (95% CI, 0.32-0.86) for low COI at birth. Similar patterns of findings were observed for children who resided in areas with lower SVI (vs very high SVI). For example, among children with obesity at age 10 years, the risk ratio was 0.17 (95% CI, 0.10-0.30) for very low SVI at birth, 0.20 (95% CI, 0.11-0.35) for low SVI at birth, 0.42 (95% CI, 0.24-0.75) for moderate SVI at birth, and 0.43 (95% CI, 0.24-0.76) for high SVI at birth. For both indices, effect estimates for mean BMI difference and obesity risk were larger at an older age of outcome measurement. In addition, exposure to COI or SVI at birth was associated with the most substantial difference in subsequent mean BMI and risk of obesity compared with exposure at later life stages.

Conclusions and Relevance

In this cohort study, residing in higher-opportunity and lower-vulnerability neighborhoods in early life, especially at birth, was associated with a lower mean BMI trajectory and a lower risk of obesity from childhood to adolescence. Future research should clarify whether initiatives or policies that alter specific components of neighborhood environment would be beneficial in preventing excess weight in children.

Demographic differences in willingness to share electronic health records in the All of Us Research Program

OBJECTIVE

Participant willingness to share electronic health record (EHR) information is central to success of the National Institutes of Health All of Us Research Program (AoURP). We describe the demographic characteristics of participants who decline access to their EHR data.

MATERIALS AND METHODS

We included participants enrolling in AoURP between June 6, 2017 and December 31, 2019 through the Trans-American Consortium for the Health Care Systems Research Network (TACH). TACH is a consortium of health care systems spanning 6 states, and an AoURP research partner.

RESULTS

We analyzed data for 25 852 participants (89.3% of those enrolled). Mean age = 52.0 years (SD 16.8), with 66.5% White, 18.7% Black/African American, 7.7% Hispanic, 32.5% female, and 76% with >a high school diploma. Overall, 2.3% of participants declined to share access to their EHR data (range across TACH sites = 1.3% to 3.5%). Younger age, female sex, and education >high school were significantly associated with decline to share EHR data, odds ratio (95% confidence interval) = 1.26 (1.19-1.33), 1.74 (1.42-2.14), and 2.44 (1.86-3.21), respectively. Results were similar when several sensitivity analyses were performed.

DISCUSSION

AoURP seeks a dataset reflecting our nation's diversity in all aspects of participation. Those under-represented in biomedical research may be reluctant to share access to their EHR data.

CONCLUSION

In our data, race and ethnicity were not independently related to participant decision to decline access to their EHR information. Results suggest that the value of the AoURP dataset is unlikely to be constrained by the size or the racial/ethnic composition of this subgroup.

Pediatric asthma incidence rates in the United States from 1980 to 2017

BACKGROUND

Few studies have examined longitudinal asthma incidence rates (IRs) from a public health surveillance perspective.

OBJECTIVE

Our aim was to calculate descriptive asthma IRs in children over time with consideration for demographics and parental asthma history.

METHODS

Data from 9 US birth cohorts were pooled into 1 population covering the period from 1980 to 2017. The outcome was earliest parental report of a doctor diagnosis of asthma. IRs per 1,000 person-years were calculated.

RESULTS

The racial/ethnic backgrounds of the 6,283 children studied were as follows: 55% European American (EA), 25.5% African American (AA), 9.5% Mexican-Hispanic American (MA) and 8.5% Caribbean-Hispanic American (CA). The average follow-up was 10.4 years (SD = 8.5 years; median = 8.4 years), totaling 65,291 person-years, with 1789 asthma diagnoses yielding a crude IR of 27.5 per 1,000 person-years (95% CI = 26.3-28.8). Age-specific rates were highest among children aged 0 to 4 years, notably from 1995 to 1999, with a decline in EA and MA children in 2000 to 2004 followed by a decline in AA and CA children in 2010 to 2014. Parental asthma history was associated with statistically significantly increased rates. IRs were similar and higher in AA and CA children versus lower but similar in EA and MA children. The differential rates by sex from birth through adolescence principally resulted from a decline in rates among males but relatively stable rates among females.

CONCLUSIONS

US childhood asthma IRs varied dramatically by age, sex, parental asthma history, race/ethnicity, and calendar year. Higher rates in the 0- to 4-year-olds group, particularly among AA/CA males with a parental history of asthma, as well as changes in rates over time and by demographic factors, suggest that asthma is driven by complex interactions between genetic susceptibility and variation in time-dependent environmental and social factors.

Pilot study of a brief provider and EMR-based intervention for overweight teens with asthma

INTRODUCTION

Asthma-related morbidity is increased in overweight patients, yet providers are given little guidance on how to discuss weight and asthma management with overweight teens.

OBJECTIVE

We piloted an electronic medical record (EMR)-based tailored discussion guide (TDG) and a brief provider training, to address weight management in overweight teens with asthma. The primary outcome was intervention impact on patient-reported asthma outcomes (e.g., asthma control and morbidity). Secondary outcomes included change in BMI, patient-centeredness, and change in healthy behaviors.

METHODS

Teens aged 13-18 years with persistent asthma and a body mass index ≥ 85th percentile for their age and sex were eligible. Parents of eligible teens were contacted before an upcoming appointment to allow teen enrollment during the clinic visit. Providers reviewed Motivational Interviewing (MI) concepts and were trained in the TDG for support of conversations around weight and asthma management. Measures included asthma outcomes retrieved from the EMR at 6- and 12-month post-baseline, teen impressions of patient-provider communication at 6-week post-enrollment, and teen report of healthy behaviors at 6- and 12-month post-baseline.

RESULTS

Of 44 teens enrolled (77% African-American, 63% female), mean BMI for intervention (n=25) and control groups (n=19) at baseline were similar. Thirty participants (68%) completed a 6-week questionnaire. Compared to controls, at 6 months, intervention teens reported fewer days of limited activity and "uncontrolled asthma," but at 12 months, only restricted activity remained lower, and BMI was not reduced. Intervention teens reported clinic visits that were more patient-centered than controls, including discussion of asthma treatment options with provider, feeling ready to follow an asthma treatment routine, and receiving helpful tips about reaching a healthy weight. The healthy behavior "dinner with family" showed improvement for intervention teens at 6 and 12 months. The feasibility study also revealed a need to improve recruitment strategies and to streamline intervention delivery.

CONCLUSION

Modest improvements in patient-reported asthma outcomes and health behaviors were observed. There was strong evidence that the TDG supports provider discussion of weight and asthma to create a more patient-centered conversation from the perspective of participating teens. Challenges to recruitment and clinic adaptation must be addressed before advancing to a full-scale trial.

TRIAL REGISTRATION

NCT02575326 Teen Asthma Control Encouraging a Healthier Lifestyle, www.cllinicaltrials.gov.

Participant-level characteristics differ by recruitment setting when evaluating a behavioral intervention targeting adolescents with asthma

OBJECTIVE

The recruitment setting plays a key role in the evaluation of behavioral interventions. We evaluated a behavioral intervention for urban adolescents with asthma in three randomized trials conducted separately in three different settings over the course of 8 years. We hypothesized that characteristics of trial participants recruited from the ED and clinic settings would be significantly different from that of youth participating in the school-based trials. The intervention evaluated was Puff City, a web-based program that uses tailoring to improve asthma management behaviors.

METHODS

The present analysis includes youth aged 13-19 years who reported a physician diagnosis of asthma and symptoms at trial baseline. In the three trials, all participants were randomized post-baseline to a web-based, tailored intervention (treatment) or generic web-based asthma education (control).

RESULTS

Compared to school-based trial participants, ED participants had significantly more acute-care visits for asthma (p < 0.001) and more caregiver depression (p < 0.001). Clinic-based participants were more likely to have computer/ internet access than participants from the school-based trial (p < 0.001). Both ED and clinic participants were more likely to report controller medication (p's < 0.001) and higher teen emotional support (p's < 0.01) when compared to the schools, but were less likely to report Medicaid (p's < 0.014) and exposure to environmental tobacco smoke (p < 0.001).

CONCLUSION

Compared to participants in the school-based trials, participants recruited from ED and clinic settings differed significantly in terms of healthcare use, as well as psychosocial and sociodemographic factors. These factors can inform intervention content, and may impact external validity of behavioral interventions for asthma.

"They're Doing Their Job": Women's Acceptance of Emergency Department Contraception Counseling

STUDY OBJECTIVE

We explore reproductive-aged women's acceptance of contraception counseling in the emergency department (ED).

METHODS

This study is phase 1 of an exploratory sequential mixed methods study. We purposively interviewed 31 participants with the following criteria: black, white, or Latina race/ethnicity; nonpregnant; aged 15 to 44 years; receiving nonemergency care; not using highly effective contraception; and did not intend to become pregnant. We conducted semistructured interviews with a piloted interview guide until reaching thematic saturation. We coded transcripts with an iteratively developed codebook, maintaining intercoder agreement greater than 80%. Qualitative acceptance of ED contraception counseling was grouped into 3 categories: acceptable, unacceptable, and equivocal. We conducted a thematic text analysis to assess themes expressing support and concern for ED contraception counseling. Qualitative findings were stratified by age, race, and frequency of ED use. Using components of grounded theory, we developed a conceptual model.

RESULTS

Most participants (81%) accepted ED contraception counseling. Themes expressing support and concern for ED contraception counseling included opportunity to address women's unmet contraception needs, contraception is within the scope of ED practice, the ED is a convenient setting with competent providers, contraception is a sensitive topic, and the ED may be an inappropriate setting for some women. Latina participants had lower acceptance of ED contraception counseling. Dominant subthemes varied slightly by race, age, and frequency of ED use.

CONCLUSION

Diverse women had high acceptance of contraception counseling in the ED. Perspectives expressing both support and concern in regard to ED contraception counseling were explored in detail.

Pilot study of a randomized trial to evaluate a Web-based intervention targeting adolescents presenting to the emergency department with acute asthma

Background

Low-income African-American adolescents use preventive medical services less frequently than their White counterparts, indicating a need for effective interventions targeting this group. Puff City is a Web-based, asthma management program for urban adolescents that has been evaluated in high school settings with promising results. The objective of this pilot was to assess the feasibility of initiating Puff City (treatment) in an emergency department setting, thereby informing the conduct of an individual randomized trial to evaluate its effectiveness compared to a generic, Web-based program (control) in preventing subsequent emergency department (ED) visits.

Methods

Teens aged 13–19 years presenting with acute asthma to two urban EDs within the study period were eligible. Subsequent ED visits were collected using the electronic medical record. A priori indication of a potential intervention effect was p < 0.20.

Results

Of the 121 teens randomized (65 treatment, 56 control), 86.0% were African-American and 44.6% male, with the mean age = 15.4 years. Computer ownership was reported by 76.8% of teens. Overall, 64.5% of teens completed >3 of 4 sessions and 90% completed the 12-month survey. At 12 months, the treatment group showed a trend toward fewer ED visits than controls (33.8 versus 46.4%), p = 0.15.

Conclusions

Results indicate the feasibility of enrolling at-risk adolescents in ED settings and set the stage for a large, pragmatic trial using a technology-based intervention to reduce the burden of pediatric asthma.

Trial registration

ClinicalTrials.gov, NCT01695031

Overweight adolescents and asthma: Revealing motivations and challenges with adolescent-provider communication

OBJECTIVE

Among teens with asthma, challenges of disease management may be greater in those with a body mass index (BMI) >85th percentile compared to youth within the parameters for normal weight-for-age. This mixed-methods study assessed teens' awareness of the link between weight and asthma management, and perspectives on how medical providers might open a discussion about managing weight.

METHOD

Teens aged 13-18, having BMI >85 percentile and chronic asthma, identified using health system databases and a staff email message board, were invited to complete a semi-structured, in-depth phone interview. Interviews were audio taped, transcribed, and qualitatively analyzed, using the Framework Method. Responses were summarized and themes identified. Descriptive summaries were generated for a 16-item survey of weight conversation starters.

RESULTS

Of 35 teens interviewed, 24 (69%) were girls, 11 (31%) boys, 20 (63%) African-American. All teens reported having "the weight conversation" with their doctors, and preferred that parents be present. Half knew from their doctor about the link between being overweight and asthma, others knew from personal experience. Nearly all expressed the importance of providers initiating a weight management conversation. Most preferred conversation starters that recognized challenges and included parents' participation in weight management; least liked referred to "carrying around too much weight."

CONCLUSIONS

Most teens responded favorably to initiating weight loss if it impacted asthma management, valued their provider addressing weight and family participation in weight management efforts. Adolescents' views enhance program development fostering more effective communication targeting weight improvement within the overall asthma management plan.

The Mental Health of Transgender Youth: Advances in Understanding

This review provides an update on the growing body of research related to the mental health of transgender youth that has emerged since the 2011 publication of the Institute of Medicine report on the health of lesbian, gay, bisexual, and transgender people. The databases PubMed and Ovid Medline were searched for studies that were published from January 2011 to March 2016 in English. The following search terms were used: transgender, gender nonconforming, gender minority, gender queer, and gender dysphoria. Age limits included the terms youth, child, children, teenager*, and adolescen*. The combined search produced 654 articles of potential relevance. The resulting abstracts went through a tiered elimination system, and the remaining 15 articles, which presented quantitative data related to the prevalence of transgender youth and their mental health, were included in the present review. In addition to providing new estimates of the number of young people who identify as transgender (.17%-1.3%), studies since 2011 have shown that transgender youth have higher rates of depression, suicidality and self-harm, and eating disorders when compared with their peers. Gender-affirming medical therapy and supported social transition in childhood have been shown to correlate with improved psychological functioning for gender-variant children and adolescents. Recent research has demonstrated increased rates of psychiatric morbidity among transgender youth compared to their peers. Future work is needed to understand those youth who identify as gender nonbinary, improve methods to capture and understand diverse gender identities and related health disparities, and delineate the social determinants of such disparities.

Examining health literacy among urban African-American adolescents with asthma

OBJECTIVE

This exploratory study assessed health literacy among urban African-American high school students to improve understanding of the association between adolescent health literacy and asthma.

METHODS

We conducted a secondary data analysis of the control group (n = 181) of the Puff City randomized controlled trial (2006-2010), a web-based intervention to promote asthma management among students, grades 9 through 12. A validated self-report 3-item health literacy screening instrument was completed at final online follow-up survey. Logistic regression was used to explore the association between health literacy, demographic characteristics, quality of life, asthma management, and health care utilization.

RESULTS

Multivariate analysis revealed that an overall inadequate health literacy score was associated with students who were more likely to be younger (OR 0.61; 95% CI 0.44-0.84), not on Medicaid (OR 0.36; 95% CI 0.17-0.76), have at least one hospitalization (OR 1.29; 95% CI 1.07-1.56); and a lower overall quality of life (OR 0.75; 95% CI 0.59-0.95). Those lacking confidence in filling out medical forms, needing help reading hospital materials, and having difficulty understanding written information were more likely to not have a rescue inhaler (OR 0.49; 95% CI 0.25-0.94), have one or more emergency visits (OR 1.21 95% CI 1.02-1.43), and one or more hospitalizations (OR 1.19; 95% CI 1.01-1.41), respectively.

CONCLUSIONS

The findings indicate a significant association between inadequate health literary and suboptimal asthma management. It is important to advance understanding of adolescent health literacy, especially those at-risk, as they assume asthma self-management tasks and move toward independent adult self-care.

Technology-Based Interventions for Asthma-Can They Help Decrease Health Disparities?

Asthma is a condition that has consistently demonstrated significant health outcome inequalities for minority populations. One approach used for care of patients with asthma is the incorporation of technology for behavioral modification, symptom monitoring, education, and/or treatment decision making. Whether such technological interventions can improve the care of black and inner-city patients is unknown. We reviewed all randomized controlled trial technological interventions from 2000 to 2015 performed in minority populations. A total of 16 articles met inclusion and exclusion criteria; all but 1 was performed in a childhood or adolescent age group. The interventions used MPEG audio layer-3 players, text messaging, computer/Web-based systems, video games, and interactive voice response. Many used tailored content and/or a specific behavior theory. Although the interventions were based on technology, most required additional special staffing. Subject user satisfaction was positive, and improvements were noted in asthma knowledge, medication adherence, asthma symptoms, and quality of life. Unfortunately, health care utilization (emergency department visits and/or hospitalizations) was typically not improved by the interventions. Although no single intervention modality was vastly superior, the computer-based interventions appeared to have the most positive results. In summary, technology-based interventions have a high level of user satisfaction among minority and urban/low-income individuals with asthma, and can improve asthma outcomes. Further large-scale studies are needed to assess whether such interventions can decrease health disparities in asthma.

Exploring racial differences in IgE-mediated food allergy in the WHEALS birth cohort

BACKGROUND

Suspected food allergies are the cause of more than 200,000 visits to the emergency department annually. Racial differences in the prevalence of food allergy have also been reported, but the evidence is less conclusive. Researchers continue to struggle with the identification of food allergy for epidemiologic studies.

OBJECTIVE

To explore racial differences in IgE-mediated food allergy (IgE-FA) in a birth cohort.

METHODS

We used a panel of board-certified allergists to systematically identify IgE-FA to egg, milk, or peanut in a multiethnic birth cohort in which patient medical history, patient symptoms, and clinical data were available through 36 months of age.

RESULTS

Of the 590 infants analyzed, 52.9% were male and 65.8% African American. Sensitization (serum specific IgE >0.35 IU/mL) to the food allergens was significantly higher for African American children compared with non-African American children as has been previously reported. No statistically significant racial/ethnic differences in IgE-FA were observed; however, a higher proportion of African American children were designated as having peanut allergy, and the percentage of African American children with an IgE level greater than 95% predictive decision points for peanut was 1.7% vs 0.5% for non-African American children. With the use of logistic regression, race/ethnicity was not significantly associated with IgE-FA (adjusted odds ratio, 1.12; 95% confidence interval, 0.58-2.17; P = .75) but was associated with sensitization to more than 1 of the food allergens (adjusted odds ratio, 1.80; 95% confidence interval, 1.22-2.65; P = .003).

CONCLUSION

We did not observe an elevated risk of IgE-FA for African American children, although established differences in sensitization were observed. Racial/ethnic differences in sensitization must be taken into consideration when investigating disparities in asthma and allergy.

Initiating an online asthma management program in urban emergency departments: the recruitment experience

BACKGROUND

The emergency department could represent a means of identifying patients with asthma who could benefit from asthma interventions.

OBJECTIVE

To assess the initiation of a Web-based tailored asthma intervention in the emergency department of 2 urban tertiary care hospitals.

METHODS

In addition to awareness strategies for emergency department staff (eg, attending nursing huddles, division meetings, etc), recruitment experiences are described for 2 strategies: (1) recruitment during an emergency department visit for acute asthma and (2) recruitment from patient listings (mail or telephone). Patient enrollment was defined as baseline completion, randomization, and completion of the first of 4 online sessions.

RESULTS

Of 499 eligible patients 13 to 19 years old visiting the emergency department for asthma during the study period, 313 (63%) were contacted in the emergency department (n = 65) or by mail or telephone (n = 350). Of these, 121 (38.6%) were randomized. Mean age of the study sample was 15.4 years and 88.4% were African American. Refusal rates for emergency department recruitment and mail or telephone were 18.5% (12 of 65) and 16.6% (58 of 350), respectively. On average, emergency department enrollment took 44 to 67 minutes, including downtime. When surveyed, emergency department providers were more positive about awareness activities and emergency department recruitment than were research staff.

CONCLUSION

Emergency department recruitment was feasible but labor intensive. Refusal rates were similar for the 2 strategies. Targeting patients with acute asthma in the emergency department is one way of connecting with youth at risk of future acute events.

Usefulness of a home affluence scale administered to urban adolescents with asthma to estimate the family's socioeconomic status

PURPOSE

Measurement of socioeconomic status (SES) is traditionally based on education, income, and occupation. This information may not be readily available from adolescents participating in research.

METHODS

Using data from school-based randomized trial of an asthma intervention targeting urban adolescents, we compared percent poverty in zip code of residence (% poverty), median housing value, and parental income and education, to teen responses on the Home Affluence Scale for Children (HASC), which included home, car, and computer ownership for the family and eligibility for free school lunch. The association of HASC with measures of asthma control was also assessed.

RESULTS

Of 422 adolescents, 390 (92%) responded to HASC items (mean HASC = 2.5). HASC was associated with mother's education and household income (both P < .001), and significantly correlated with % poverty (P < .0001) and median home value (P = .003). The association of HASC <2.0 to indicators of uncontrolled asthma was in the direction hypothesized, especially for nighttime symptoms, odds ratio (95% confidence interval) = 1.59 (0.95-2.66) and restricted activity, odds ratio = 1.87 (1.12-3.12).

CONCLUSIONS

HASC correlates well with more traditional measures of SES, and the risk estimates for HASC less than 2.0 and indicators of uncontrolled asthma were mostly in the hypothesized direction. Methods of obtaining SES indicators from youth are needed for research studies.

Comparison of asthma prevalence among African American teenage youth attending public high schools in rural Georgia and urban Detroit

BACKGROUND

The high prevalence of asthma among urban African American (AA) populations has attracted research attention, whereas the prevalence among rural AA populations is poorly documented.

OBJECTIVE

We sought to compare the prevalence of asthma among AA youth in rural Georgia and urban Detroit, Michigan.

METHODS

The prevalence of asthma was compared in population-based samples of 7297 youth attending Detroit public high schools and in 2523 youth attending public high schools in rural Georgia. Current asthma was defined as a physician diagnosis and symptoms in the previous 12 months. Undiagnosed asthma was defined as multiple respiratory symptoms in the previous 12 months without a physician diagnosis.

RESULTS

In Detroit, 6994 (95.8%) youth were AA compared with 1514 (60.0%) in Georgia. Average population density in high school postal codes was 5628 people/mile(2) in Detroit and 45.1 people/mile(2) in Georgia. The percentages of poverty and of students qualifying for free or reduced lunches were similar in both areas. The prevalence of current diagnosed asthma among AA youth in Detroit and Georgia was similar: 15.0% (95% CI, 14.1-15.8) and 13.7% (95% CI, 12.0-17.1) (P = .22), respectively. The prevalence of undiagnosed asthma in AA youth was 8.0% in Detroit and 7.5% in Georgia (P = .56). Asthma symptoms were reported more frequently among those with diagnosed asthma in Detroit, whereas those with undiagnosed asthma in Georgia reported more symptoms.

CONCLUSIONS

Among AA youth living in similar socioeconomic circumstances, asthma prevalence is as high in rural Georgia as it is in urban Detroit, suggesting that urban residence is not an asthma risk factor.

Time Spent on the Internet and Adolescent Blood Pressure

Internet use is nearly ubiquitous among adolescents. Growing evidence suggests heavy Internet use negatively impacts health, yet the relationship between time spent on the Internet and adolescent blood pressure (BP) is unknown. We examined the association between Internet use and elevated BP in a racially diverse cross-sectional sample of 331 healthy adolescents (ages 14–17 years). Heavy Internet use was defined as ≥2 hr/day, moderate use as <2 hr/day and ≥5 days/week, and light use as <2 hr/day and ≤4 days/week. Elevated BP was defined as systolic or diastolic BP ≥90th percentile. Heavy Internet users had statistically significantly higher odds of elevated BP compared to light Internet users. School nurses can play an important role in preventing high BP through assessment of BP and other health behaviors including Internet use, and health teaching to individuals, student groups, faculty, and parents to increase awareness of the relationship between Internet use and health.

Use of an interactive, faith-based kiosk by congregants of four predominantly, african-american churches in a metropolitan area

Chronic diseases are prevalent in ethnic communities. Churches represent a potent resource for targeted health promotion. A faith-based kiosk was developed as an informational tool and placed in four predominantly (>80%) African-American churches. Congregants were surveyed to describe kiosk-use, kiosk-user characteristics, health status, and self-reported behavior changes attributed to the kiosk. We analyzed 1,573 questionnaires. Mean age of respondents was 46.4 years and >70% were women. “Older” congregations (mean age ≥46.1 years) had more reports of diabetes (p = 0.002) and heart diseases (p = 0.01) than younger churches (mean age ≤44.1), whereas asthma was more prevalent in the latter (p < 0.001). Prevalence of obesity (40%) was similar across churches (p = 0.570). Kiosk-use was reported by 420 (26.7%) respondents. Compared to non-users, kiosk-users were >40 years (p < 0.001), and reported >two health conditions, adjusted Odds Ratio (95% Confidence Interval) = 1.43 (1.0–2.0), p = 0.05. Male kiosk-users preferred to select disease-specific content, aOR = 1.87 (1.10–3.17), p = 0.02, while females tended to select information about supportive community resources, aOR = 0.49 (0.23–1.04), p = 0.062. Knowledge of kiosk-user characteristics and the “health status” of a congregation, provide an opportunity for targeted, church-based health promotion.

Improving efficiency and reducing costs: Design of an adaptive, seamless, and enriched pragmatic efficacy trial of an online asthma management program

Clinical trials are critical for medical decision-making, however, under the current paradigm, clinical trials are fraught with problems including low enrollment and high cost. Promising alternatives to increase trial efficiency and reduce costs include the use of (1) electronic initiatives that permit electronic remote data capture (EDC) for direct data collection at a site (2), electronic medical records (EMR) for patient identification and data collection, and (3) adaptive, enrichment designs with pragmatic approaches. We describe the design of a seamless, multi-site randomized Phase II/III trial to evaluate an asthma management intervention in urban adolescents with asthma. Patients are randomized, asked to access four online sessions of the intervention or control asthma management program, and are then followed for one year. The primary efficacy endpoint is self-reported asthma control as measured by the Asthma Control Test (ACT). Comparative effectiveness parametric approaches are utilized to conduct the trial in a real world setting with reduced costs. Escalated electronic initiatives are implemented for patient identification, assent, enrollment and tracking. Patient enrollment takes place during primary care visits. A centralized database with EDC is used for CRF data collection with integration of EMR data. This Phase II/III trial plans to have a total sample size of 500 patients with an interim look at the completion of Phase II (n=250), The interim analyses include an assessment of the intervention effect, marker(s) identification and the feasibility study of EMR data as the trial CRF data collection. Patient enrollment has begun and is ongoing.

Atopic phenotypes identified with latent class analyses at age 2 years

BACKGROUND

Atopic sensitization (ie, atopy) is the most commonly reported risk factor for asthma. Recent studies have begun to suggest that atopy, as conventionally defined, might be an umbrella term that obfuscates more specific allergic disease types.

OBJECTIVE

We sought to determine whether distinct and meaningful atopic phenotypes exist within a racially diverse birth cohort using 10 allergen-specific serum IgE (sIgE) measurements from children aged 2 years.

METHODS

Using the Wayne County Health, Environment, Allergy and Asthma Longitudinal Study (WHEALS) birth cohort (62% black), we analyzed sIgE data on 10 allergens (Dermatophagoides farinae, dog, cat, timothy grass, ragweed, Alternaria alternata, egg, peanut, milk, and German cockroach) obtained from 594 children at age 2 years. Conventional atopy was defined as at least 1 sIgE level of 0.35 IU/mL or greater.

RESULTS

A 4-class solution (latent class model) was the best fit. Class types were labeled "low to no sensitization" (76.9% of sample), "highly sensitized" (2.7%), "milk and egg dominated" (15.3%), and "peanut and inhalant(s)" (5.1%). Almost one third (32.2%) of the low to no sensitization group met the criteria for conventional atopy. The highly sensitized group was significantly associated with a doctor's diagnosis of asthma after age 4 years (odds ratio [OR], 5.3; 95% CI, 1.6-17.4), whereas the milk and egg dominated and peanut and inhalant(s) groups were not (ORs of 1.6 [95% CI, 0.8-3.0] and 1.8 [95% CI, 0.6-4.9], respectively). Children of black race were more likely to be in the 3 multisensitized groups (P = .04).

CONCLUSION

Classification by sIgE patterns defined groups whose membership is more strongly associated with atopic dermatitis, wheeze, and asthma compared with conventional atopy.

Prenatal dog-keeping practices vary by race: speculations on implications for disparities in childhood health and disease

OBJECTIVE

There is consistent evidence demonstrating that pet-keeping, particularly of dogs, is beneficial to human health. We explored relationships between maternal race and prenatal dog-keeping, accounting for measures of socioeconomic status that could affect the choice of owning a pet, in a demographically diverse, unselected birth cohort.

DESIGN

Self-reported data on mothers' race, socioeconomic characteristics and dog-keeping practices were obtained during prenatal interviews and analyzed cross-sectionally. Robust methods of covariate balancing via propensity score analysis were utilized to examine if race (Black vs White), independent of other participant traits, influenced prenatal dog-keeping.

SETTING

A birth cohort study conducted in a health care system in metropolitan Detroit, Michigan between September 2003 and November 2007.

PARTICIPANTS

1065 pregnant women (n=775 or 72.8% Black), between ages 21 and 45, receiving prenatal care.

MAIN OUTCOME MEASURES

Participant's self-report of race/ethnicity and prenatal dog-keeping, which was defined as her owning or caring for > or =1 dog for more than 1 week at her home since learning of her pregnancy, regardless of whether the dog was kept inside or outside of her home.

RESULTS

In total, 294 women (27.6%) reported prenatal dog-keeping. Prenatal dog-keeping was significantly lower among Black women as compared to White women (20.9% vs 45.5%, P<.001), and remained significantly different even after propensity score analysis was applied.

CONCLUSION

Findings suggest that there are persistent racial differences in dog-keeping not fully explained by measures of socioeconomic status. Racial differences in prenatal dog-keeping may contribute to childhood health disparities.

Reconnecting with urban youth enrolled in a randomized controlled trial and overdue for a 12-month follow-up survey

BACKGROUND

Retention of study participants in randomized controlled trials (RCTs) is crucial to study validity.

PURPOSE

We analyzed the results of four retention strategies used to reconnect with urban teens enrolled in a school-based RCT and overdue for a 12-month follow-up survey.

METHODS

Traditional retention strategies used to reconnect with teens categorized as 'unable to contact' were weekly redials of nonworking telephone numbers and mailings to the student's home. Nontraditional retention strategies were obtaining assistance from school administration and performing outreach on Facebook.

RESULTS

Of the 422 students enrolled, 125 (29.5%) were overdue for a 12-month follow-up survey, but had no working telephone number (unable to contact). We made 196 attempts to contact these 125 students, of which 82 attempts (41.8%) were successful in 'reconnecting' with the student. Using 'mailed reminder letters' as the referent category, odds ratios (95% confidence intervals) for the association between the strategy used and reconnecting were 4.60 (1.8-11.8), 1.94 (1.01-3.73), and 2.91 (0.58-14.50), respectively, for telephone number redials, Facebook outreach, and school administration assistance. Of the 422 students, 380 (90%) ultimately completed the 12-month follow-up survey.

LIMITATIONS

Retention strategies were not applied hierarchically or systematically. We were unable to determine student preference for a particular strategy. Findings are likely only applicable to similar study populations.

CONCLUSION

A mix of traditional retention strategies and more contemporary methods was effective in reconnecting with urban teenagers enrolled in a school-based RCT and in controlling attrition during the 12-month follow-up survey period.

Evaluation of a web-based asthma management intervention program for urban teenagers: reaching the hard to reach

PURPOSE

Asthma interventions targeting urban adolescents are rare, despite a great need. Motivating adolescents to achieve better self-management of asthma is challenging, and the literature suggests that certain subgroups are more resistant than others. We conducted a school-based, randomized controlled trial (RCT) to evaluate Puff City, a Web-based, tailored asthma intervention, which included a referral coordinator, and incorporated theory-based strategies to target urban teens with characteristics previously found to be associated with lack of behavior change.

METHODS

To identify eligible teens, we administered questionnaires on asthma diagnoses and symptoms to ninth through 12th graders of participating schools during a scheduled English class. We randomized eligible, consenting students to Puff City (treatment) or generic asthma education (control).

RESULTS

We randomized 422 students (98% African-American, mean age = 15.6 years). At 12-month follow-up, adjusted odds ratios (aORs) (95% confidence intervals) indicated intervention benefit for treatment teens for symptom-days and restricted activity days (analyzed as categorical variables) as aOR = .49 (.24-.79), p = .006 and .53 (.32-.86), p = .010, respectively. Among teens meeting baseline criteria for rebelliousness, treatment teens reported fewer symptom-days, symptom-nights, school absences, and restricted activity days: aOR = .30 (.11-.80), .29 (.14-.64), .40 (.20-.78), and .23 (.10-.55); all p < .05. Among teens reporting low perceived emotional support, treatment students reported only fewer symptom-days than controls: aOR = .23 (.06-.88), p = .031. We did not observe statistically significant differences in medical care use.

CONCLUSIONS

Results suggest that a theory-based, tailored approach, with a referral coordinator, can improve asthma management in urban teens. Puff City represents a viable strategy for disseminating an effective intervention to high-risk and hard-to-reach populations.

Racial disparities in allergic outcomes in African Americans emerge as early as age 2 years

BACKGROUND

Racial disparities in allergic disease outcomes have been reported with African Americans suffering disproportionately compared to White individuals.

OBJECTIVE

To examine whether or not racial disparities are present as early as age 2 years in a racially diverse birth cohort in the Detroit metropolitan area.

METHODS

All children who were participants in a birth cohort study in the Detroit metropolitan area were invited for a standardized physician exam with skin prick testing and parental interview at age 2 years. Physicians made inquiries regarding wheezing and allergy symptoms and inspected for and graded any atopic dermatitis (AD). Skin testing was performed for Alternaria, cat, cockroach, dog, Dermatophagoides farinae (Der F), Short Ragweed, Timothy grass, egg, milk and peanut. Specific IgE was measured for these same allergens and total IgE was determined.

RESULTS

African American children (n = 466) were more likely than White children (n = 223) to have experienced any of the outcomes examined: at least 1 positive skin prick test from the panel of 10 allergens (21.7% vs. 11.0%, P = 0.001); at least one specific IgE ≥ 0.35 IU/mL (out of a panel of 10 allergens) (54.0% vs. 42.9%, P = 0.02); had AD (27.0% vs. 13.5%, Chi-square P < 0.001); and to ever have wheezed (44.9% vs. 36.0%, P = 0.03). African American children also tended to have higher total IgE (geometric means 23.4 IU/mL (95%CI 20.8, 27.6) vs. 16.7 IU/mL (95%CI 13.6, 20.6 IU/mL), Wilcoxon Rank Sum P = 0.004). With the exception of wheezing, the associations did not vary after adjusting for common social economic status variables (e.g. household income), environmental variables (endotoxin; dog, cat and cockroach allergen in house dust) or variables that differed between the racial groups (e.g. breastfeeding). After adjustment, the wheeze difference was ameliorated.

CONCLUSIONS

With disparities emerging as early as age 2 years, investigations into sources of the disparities should include the prenatal period and early life.

Effect of depressive symptoms on asthma intervention in urban teens

BACKGROUND

The literature suggests that depression is an important comorbidity in asthma that can significantly influence disease management and quality of life (QOL).

OBJECTIVE

To study the effect of coexisting depressive symptoms on the effectiveness of self-management interventions in urban teens with asthma.

METHODS

We analyzed data from a randomized controlled trial of Puff City, a web-based, tailored asthma management intervention for urban teens, to determine whether depression modulated intervention effectiveness for asthma control and QOL outcomes. Teens and caregivers were classified as depressed based on responses collected from baseline questionnaires.

RESULT

Using logistic regression analysis, we found that a lower percentage of treatment students had indicators of uncontrolled asthma compared with controls (adjusted odds ratios <1). However, for teens depressed at baseline, QOL scores at follow-up were significantly higher in the treatment group compared with the control group for the emotions domain (adjusted relative risk, 2.08; 95% confidence interval, 1.2-3.63; P = .01; interpreted as emotional QOL for treatment students increased by a factor of 2.08 above controls). Estimates for overall QOL and symptoms QOL were borderline significant (adjusted relative risk, 1.57; 95% confidence interval, 0.93-2.63; P = .09; and adjusted relative risk, 1.72; 95% confidence interval, 0.94-3.15; P = .08; respectively). Among teens not depressed at baseline, no significant differences were observed between treatment and control groups in QOL domains at follow-up.

CONCLUSION

Our results suggest that depression modified the relationship between the effectiveness of an asthma intervention and emotional QOL in urban teens. Further assessment of self-management behavioral interventions for asthma should explore the mechanism by which depression may alter the intervention effect.

Sensitization and allergic histories differ between black and white pregnant women

BACKGROUND

Racial differences in allergic diseases have been reported, with black subjects suffering disproportionately compared with white subjects, although such studies have been more commonly done in pediatric populations.

OBJECTIVE

We sought to determine whether there are differences in rates of allergic sensitization or prior diagnoses of asthma, hay fever, or eczema in black and white pregnant women.

METHODS

Women were recruited during pregnancy (regardless of allergic history) as part of a birth cohort study in the Detroit metropolitan area and were interviewed about prior doctors' diagnoses of asthma, hay fever/nasal allergies/allergic rhinitis, and eczema. Blood samples were collected, total IgE levels were determined, and specific IgE levels were measured for Alternaria alternata, cat, cockroach, dog, Dermatophagoides farinae, short ragweed, timothy grass, and egg.

RESULTS

Black women (n = 563) were more likely than white women (n = 219) to have had at least 1 specific IgE level of 0.35 IU/mL or greater (62.5% vs 40.2%, P < .001). Black women had higher total IgE levels (geometric mean, 47.8 IU/mL [95% CI, 42.5-53.8 IU/mL] vs 20.0 IU/mL [95% CI, 16.2-24.6 IU/mL]; P < .001, Wilcoxon rank sum test). Black women were more likely to have had a prior doctor's diagnosis of asthma (22.7% vs 16.0%, P = .04) and eczema (21.9% vs 14.8%) but not hay fever (white women: 17.5% vs black women: 15.7%, P = .55). Associations persisted for total IgE levels, having 1 or more positive allergen-specific IgE levels, and eczema after adjusting for common socioeconomic or environmental variables.

CONCLUSIONS

Racial differences in allergic sensitization and diagnoses were present, even after controlling for various factors. Future research should focus on prevention to ameliorate these disparities.

Comparison of early-, late-, and non-participants in a school-based asthma management program for urban high school students

Background

To assess bias and generalizability of results in randomized controlled trials (RCT), investigators compare participants to non-participants or early- to late-participants. Comparisons can also inform the recruitment approach, especially when working with challenging populations, such as urban adolescents. In this paper, we describe characteristics by participant status of urban teens eligible to participate in a RCT of a school-based, web-based asthma management program.

Methods

The denominator for this analysis was all students found to be eligible to participate in the RCT. Data were analyzed for participants and non-participants of the RCT, as well as for students that enrolled during the initially scheduled recruitment period (early-participants) and persons that delayed enrollment until the following fall when recruitment was re-opened to increase sample size (late-participants). Full Time Equivalents (FTEs) of staff associated with recruitment were estimated.

Results

Of 1668 teens eligible for the RCT, 386 enrolled early, and 36 enrolled late, leaving 1246 non-participants. Participants were younger (p < 0.01), more likely to be diagnosed, use asthma medication, and have moderate-to-severe disease than non-participants, odds ratios (95% Confidence Intervals) = 2.1(1.7-2.8), 1.7(1.3-2.1), 1.4(1.0-1.8), respectively. ORs were elevated for the association of late-participation with Medicaid enrollment, 1.9(0.7-5.1) and extrinsic motivation to enroll, 1.7(0.6-5.0). Late-participation was inversely related to study compliance for teens and caregivers, ORs ranging from 0.1 to 0.3 (all p-values < 0.01). Early- and late-participants required 0.45 FTEs/100 and 3.3 FTEs/100, respectively.

Conclusions

Recruitment messages attracted youth with moderate-to-severe asthma, but extending enrollment was costly, resulting in potentially less motivated, and certainly less compliant, participants. Investigators must balance internal versus external validity in the decision to extend recruitment. Gains in sample size and external validity may be offset by the cost of additional staff time and the threat to internal validity caused by lower participant follow-up.

Trial Registration

ClinicalTrials.gov: NCT00201058

Factors associated with nonresponse to a computer-tailored asthma management program for urban adolescents with asthma

BACKGROUND

The ability to identify potentially resistant participants early in the course of an intervention could inform development of strategies for behavior change and improve program effectiveness.

OBJECTIVE

The objective of this analysis was to identify factors related to nonresponse (i.e., lack of behavior change) to an asthma management intervention for urban teenagers. The intervention targeted several behaviors, including medication adherence, having a rescue inhaler nearby, and smoking.

METHODS

A discriminate analysis was conducted using data from a randomized trial of the intervention. Included in this analysis are participants who reported a physician diagnosis of asthma, completed a baseline questionnaire, were randomized to the treatment group, completed >or=2 of 4 educational sessions, and completed >or=2 of 3 follow-up questionnaires. Ninety students met criteria for inclusion in this subgroup analysis.

RESULTS

In logistic regression models for medication adherence, nonresponse was related to low baseline asthma self-regulation, odds ratio = 3.6 (95% confidence interval = 1.3-9.5). In models for having an inhaler nearby, nonresponse was related to low baseline self-regulation and to rebelliousness, OR = 4.7 (1.6-13.2) and 5.6 (1.7-18.0), respectively. Nonresponse to smoking messages was related to rebelliousness, low emotional support, and low religiosity, ORs = 7.6 (1.8-32.3), 9.5 (1.4-63.5), and 6.6 (1.5-29.8) respectively.

CONCLUSIONS

Certain variables had the ability to discriminate the likelihood of response from that of nonresponse to an asthma program for urban, African American adolescents with asthma. These variables can be used to identify resistant subgroups early in the intervention, allowing the application of specialized strategies through tailoring. These types of analyses can inform behavioral interventions.

Hair care practices and their association with scalp and hair disorders in African American girls

BACKGROUND

Few studies have extensively examined the prevalence of hair care practices and their association with scalp and hair conditions in African American girls.

OBJECTIVES

We sought to determine the prevalence of hair care practices and their association with traction alopecia, seborrheic dermatitis (SD), and tinea capitis (TC).

METHODS

A questionnaire was administered to caregivers of African American girls aged 1 to 15 years. Multivariate analyses were performed to determine the association of hair care practices with reported disorders.

RESULTS

A total of 201 surveys were completed from dermatology (n = 98) and nondermatology (n = 103) clinics. Mean patient age was 9.8 ± 4.4 years. Essentially all respondents reported use of hair oils/grease (99%). Ponytails, braids, and cornrows were worn by 81%, 67%, and 49% of girls, respectively, within the past 12 months. In all, 61% reported hair washing every 2 weeks; 80% used hot combs; and 42% used chemical relaxers. Cornrows were significantly related to traction alopecia among respondents from nondermatology clinics only: adjusted odds ratio = 5.79 (95% CI 1.35-24.8, P = .018). Hair extensions and infrequent hair oil use were significantly related to SD: adjusted odds ratio = 2.37 (95% CI 1.03-5.47, P = .04) and 3.69 (95% CI 1.07-12.7, P = .039), respectively. No significant associations were observed for TC.

LIMITATIONS

Small sample size and disorders reported by caregivers were limitations.

CONCLUSIONS

Certain hair care practices were strongly associated with development of traction alopecia and SD. No association was found between hair washing frequency and SD or TC, or between hair grease use and TC. These results can be used to inform practitioners, advise parents, and adapt treatment regimens to accommodate cultural preferences.

Variation of dust endotoxin concentrations by location and time within homes of young children

Endotoxin may affect the development of allergic disease in childhood but little is known about endotoxin variation within homes. We sought to determine endotoxin concentration agreement within homes when five locations were each sampled twice 5 months apart. Endotoxin was measured using the recombinant Limulus factor C assay in dust samples from 585 homes of children enrolled in a prospective study and again in 335 homes 5 months later. The five locations sampled in each home were the child's bedroom floor, child's bed, mother's bedroom floor, mother's bed and living room floor. Concentrations of 4 allergens (Can f 1, Fel d 1, Der f 1 and Bla g 2) were also measured from the child's bedroom floor. In pair-wise comparisons, endotoxin concentrations in all locations within each home were significantly different from all other locations (p < 0.001) except for the child's and mother's bedroom floors (p = 0.272). Spearman correlations between endotoxin concentrations from the different locations were all statistically significant (p < 0.05) but of modest magnitude (r = 0.24-0.54). Similarly, correlations at each site over the 5 month observation interval were statistically significant but modest (r = 0.17-0.44). Pets and season of the year did not affect correlations, although correlations were lower if the floor was not carpeted. Endotoxin concentrations at all locations were minimally correlated with allergen concentrations in both negative and positive directions (r = -0.12 to 0.12). We conclude that a single measurement of endotoxin from a home dust sample provides an imprecise estimate of dust endotoxin concentrations in other locations within the home and over a relatively short observation interval.

Exemplary data set sample size calculation for Wilcoxon-Mann-Whitney tests

Zhao, Rahardja and Qu consider sample size calculation for Wilcoxon-Mann-Whitney (WMW) tests for data with ties, and present a straightforward formula. We observe that the 'exemplary data set' approach, usually applied in more complex situations, has a close relationship to the Zhao-Rahardja-Qu method for WMW sample size estimation and they are asymptotically equivalent. Therefore, the exemplary data set approach can be used to easily obtain estimates similar to those that the closed formula gives. We illustrate application of both methods for a WMW sample size estimation example, and also extend the simulation study presented by Zhao et al. We find that the Zhao-Rahardja-Qu formula (and by extension the exemplary data set method) can give estimates just as accurate as those obtained using either the Kolassa approach (via nQuery Advisor) or the O'Brien-Castelloe approach (via SAS 9.2 PROC POWER), for 1:1 and 1:2 allocation ratios. However, the latter two methods can be more accurate for a ratio of 1:4 or 1:19. Finally, we note the general utility of the exemplary data set approach for sample size estimation, even in other situations where closed-form sample size formulae exist.

Gender differences in the association of overweight and asthma morbidity among urban adolescents with asthma

Asthma and obesity disproportionately affect US African-American youth. Among youth with asthma, obesity has been associated with poor control. The impact of gender on this association is unclear. We examined these relationships in a sample of urban, African-American adolescents with asthma. Questionnaires were used to identify high school students with asthma, and to examine the association of body mass index (BMI) to asthma morbidity, by gender. Of 5967 students completing questionnaires, 599 (10%) met criteria for asthma and 507 had data sufficient for inclusion in further analyses (46% male, mean age = 15.1 yr). Univariately, BMI > 85th percentile was significantly related only to reported emergency department visits (ED) and school days missed for any reason, Odds Ratio (95%Confidence Interval) = 1.7(1.1-2.7), p = 0.01 and 1.8(1.1-3.0), p = 0.01, respectively. A significant gender-BMI interaction (p < 0.05) was observed in multivariate models for ED visits, hospitalizations and school days missed for asthma. In gender-specific models, adjusted Risk Ratios for BMI > 85th and ED visits, hospitalizations, and school days missed because of asthma were 1.7(0.9-3.2), 6.6(3.1-14.6) and 3.6(1.8-7.2) in males. These associations were not observed in females. Gender modifies the association between BMI and asthma-related morbidity among adolescents with asthma. Results have implications for clinical management as well as future research.

A web-based, tailored asthma management program for urban African-American high school students

RATIONALE

Urban African-American youth, aged 15-19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing.

OBJECTIVES

Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses "tailoring," in conjunction with theory-based models, to alter behavior through individualized health messages based on the user's beliefs, attitudes, and personal barriers to change.

METHODS

High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers.

MEASUREMENTS AND MAIN RESULTS

Functional status and medical care use were measured at study initiation and 12 months postbaseline, as were selected management behaviors. The intervention period was 180 days (calculated from baseline). A total of 314 students were randomized (98% African American, 49% Medicaid enrollees; mean age, 15.2 yr). At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students; adjusted relative risk and 95% confidence intervals were as follows: 0.5 (0.4-0.8), p = 0.003; 0.4 (0.2-0.8), p = 0.009; 0.3 (0.1-0.7), p = 0.006; 0.5 (0.3-0.8), p = 0.02; and 0.2 (0.2-0.9), p = 0.01, respectively. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per participating treatment group student.

CONCLUSIONS

A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population.

The relationship between seroatopy and symptoms of either allergic rhinitis or asthma

BACKGROUND

Epidemiologic data on allergic rhinitis and asthma are frequently based on self-reported symptoms.

OBJECTIVE

This cross-sectional study examined the relationship between self-reported symptoms and histories of allergic rhinitis or asthma and a marker of allergic sensitization, allergen-specific IgE.

METHODS

We surveyed 702 pregnant women in Michigan. Blood samples were analyzed for specific IgE to 9 allergens: dust mites (Dermatophagoides farinae and Dermatophagoides pteronyssinus), cat, dog, cockroach, ragweed, timothy grass, egg, and Alternaria alternata. Seratopy was defined as a specific IgE greater than or equal to 0.35 kU/L to any allergen.

RESULTS

Seroatopy was found in 66.7% of those with hay fever symptoms, 68.3% with a physician's diagnosis of asthma, and 72.1% of those with both conditions. These results differed significantly from asymptomatic subjects, where 49.8% of patients without hay fever and 50.4% without asthma were seroatopic. Race and education did not modify the relationships. Symptoms related to specific exposures were modest predictors of positive specific IgE to related allergens (positive predictive values from 26.5% to 50.3%).

CONCLUSION

Self-reported symptoms of allergic rhinitis or asthma were significantly associated with allergic sensitization, but the odds ratios were of relatively low magnitude for this historical information to be considered evidence of current allergic sensitization. A 66% to 68% probability existed that those with symptoms of allergic rhinitis or asthma would have a positive specific IgE test.

CLINICAL IMPLICATIONS

Self-reported histories of hay fever or asthma alone are only modest predictors of allergic sensitization. When knowledge of allergic sensitization is important, information beyond self-reported symptoms is necessary.

Identifying students with self-report of asthma and respiratory symptoms in an urban, high school setting

Strategies for identifying urban youth with asthma have not been described for high school settings. African-American high school students are rarely included in asthma studies, despite a high risk of asthma mortality when compared to other age and race groups. Identification and follow-up of children with uncontrolled respiratory symptoms are necessary to reduce the burden of asthma morbidity and mortality, especially in underserved areas. We describe a process used to identify high school students who could benefit from intervention based on self-report of asthma and/or respiratory symptoms, and the costs associated with symptom-identification. Letters announcing a survey were mailed to parents of 9th-11th graders by an authorized vendor managing student data for the school district. Scan sheets with student identifiers were distributed to English teachers at participating schools who administered the survey during a scheduled class. Forms were completed by 5,967 of the 7,446 students assigned an English class (80% response). Although prevalence of lifetime asthma was 15.8%, about 11% of students met program criteria for enrollment through report of an asthma diagnosis and recent symptoms, medication use, or health care utilization. Another 9.2% met criteria by reported symptoms only. Cost of symptom-identification was $5.23/student or $32.29/program-eligible student. There is a need for school-based asthma programs targeting urban adolescents, and program initiation will likely require identification of students with uncontrolled symptoms. The approach described was successfully implemented with a relatively high response rate. Itemized expenses are presented to facilitate modifications to reduce costs. This information may benefit providers, researchers, or administrators targeting similar populations.

Collaborative design and implementation of a multisite community coalition evaluation

Evaluation designs assessing community coalitions must balance measures of how coalitions do their work and evidence that the coalitions are making a difference. The Allies cross-site evaluation attempts to determine the combined effects of the seven coalitions' work at the individual, organizational, and community levels. Principal components considered are (a) contextual factors of the coalition community, (b) coalition processes and structure, (c) planning and planning products, (d) implementation actions, (e) activities and collaborations, (f) anticipated intermediate outcomes, and (g) expected asthma related health outcomes. Measurements are quantitative and qualitative, and data generated by these methods are used as ends in themselves and as a way to confirm or inform other measures. Evaluation has been an integral part of the planning and implementation phases of the Allies coalition work, with a priority of involving all of the partners in conceiving of and deciding upon the elements of assessment.

Agreement between teenager and caregiver responses to questions about teenager's asthma

It is unknown if teenagers and caregivers give similar responses when interviewed about the teen's asthma. We analyzed data for 63 urban African-American teen-caregiver pairs. Caregivers underestimated teen smoking by 30%, gave lower estimates for teen exposure to passive smoke, and disagreed with teens on controller medication usage. Teen-caregiver responses were not significantly different for estimates of symptom-days, activity limitations, or nights awakened; nor were they significantly different for report of emergency department visits or hospitalizations. Agreement was weak for perceived asthma control and severity. Teen-caregiver agreement on asthma depends on the type of information being sought.

Applying epidemiologic concepts of primary, secondary, and tertiary prevention to the elimination of racial disparities in asthma

Despite medical and scientific advances, racial and ethnic disparities persist in US asthma morbidity and mortality rates. Progress in the elimination of these disparities will involve disentangling the contribution of social constructs, such as race, socioeconomic status, and culture, from that of the physical environment and genetic susceptibility. One approach to reducing asthma disparities is through the traditional disease prevention stages of intervention. As such, primary prevention targets reductions in asthma incidence; secondary prevention is the mitigation of established disease and involves disease detection, management, and control; and tertiary prevention is the reduction of complications caused by severe disease. Once causative factors at each level of disease prevention are understood, this knowledge can be translated into clinical practice and public health policy.