We enrolled 150 caregivers of children with asthma and 150 caregivers of children without asthma. The participants were 90% African-American, and 44% reported an annual household income below $25,000 (). Caregivers of children without asthma were similar to caregivers of children with asthma. The majority were mothers (87%) with a median age of 28 (data not shown).
Baseline characteristics of caregivers of children with and without asthma in Baltimore, Maryland (n = 300)
Reports of neighborhood violence
Among all 300 study subjects, 67 (22%) had a homicide within 500 ft of their enrollment address in 2001 (). Having a homicide within 500 ft of the home increased the odds of caregiver fear of neighborhood violence [OR (95% CI): 2.2 (1.2, 3.8); p = 0.006] and awareness of a recent violent event in the neighborhood [OR (95% CI): 2.0 (1.1, 3.5); p = 0.015]. More specifically, caregivers who reported awareness of a murder in the neighborhood in the past 6 months were more than twice as likely to have had a homicide within 500 ft of the home [OR (95% CI): 2.4 (1.3, 4.5); p = 0.007]. Nearby homicide also increased the odds of a history of personal or family member victimization, but the result was not significant [OR (95% CI): 1.5 (0.8, 2.8); p = 0.18]. Limiting the analysis to only caregivers of children with asthma did not alter the direction of these findings, though in the smaller sample not all results were statistically significant (not shown).
Caregivers of children with asthma
As we were primarily interested in the effects of neighborhood violence among caregivers of children with asthma, we performed the remainder of our analyses among this group alone. Almost half (49%) of the caregivers were aware of a recent violent event in their neighborhood (). The most commonly reported recent violent event was a violent argument between neighbors (41%) and 21% knew of a murder in their neighborhood in the past 6 months (). Of those who knew of a murder, most (80%) knew of more than one murder in their neighborhood in the past 6 months. We found that 45 (30%) of 150 caregivers of children with asthma screened positive for depression. More than one-third (36%) of caregivers described being afraid that they would be hurt by neighborhood violence, whereas 33 participants (22%) reported that, while living in the neighborhood, someone had used violence against them or a member of their family.
Caregivers of children with asthma: awareness of recent violent events in the neighborhood
Among those who were aware of a neighborhood violent event, 49% were afraid of neighborhood violence, and 32% had been a victim or had a family member who had been a victim of neighborhood violence. Of caregivers of children with asthma who had been victims of violence themselves or who had a family member who had been a victim of violence, 70% were afraid of violence in their neighborhood.
Being afraid of neighborhood violence was strongly associated with screening positive for depression [unadjusted OR (95% CI): 3.8 (1.8, 7.8); p < 0.001] (). A history of personal or family member victimization also increased the odds of screening positive for depression by 3.0 [unadjusted (95% CI: 1.3, 6.6; p = 0.008)]. In contrast, awareness of a recent violent event in the neighborhood was not significantly associated with screening positive for depression [unadjusted OR (95% CI): 0.9 (0.4, 1.7); p = 0.68]. Age of caregiver, income, and race/ethnicity were not related to screening positive for depression [OR = 1.01 (95% CI: 0.97, 1.05); p = 0.56 for age; OR = 0.91 (95% CI: 0.78, 1.06); p = 0.22 for income; OR = 1.11; (95% CI: 0.34, 3.70); p = 0.86 for race/ethnicity].
Depression and experience with violence among caregivers of children with asthma
Results of multilevel analysis
After adjusting for individual characteristics and clustering by neighborhood, being afraid of neighborhood violence remained significantly associated with screening positive for depression [OR (95% CI): 6.8 (3.2, 13.5); p < 0.001] (). History of personal or family victimization was associated with a possible trend towards screening positive for depression [OR (95% CI): 2.1 (0.9, 5.0); p = 0.08] compared to those who had no such history, although the results did not reach statistical significance. Awareness of a recent violent event in the neighborhood did not increase the odds of screening positive for depression [OR (95% CI): 0.4 (0.1, 1.0); p = 0.054].
Although prior work has not found interactions between questionnaire-based measures of community violence (Sampson et al., 1997
; Wright et al., 2004
), it is conceivable that our measures of community violence might covary or interact. Nonetheless, we found no significant interaction or covariance between our measures of community violence. Homicide within 500 ft of enrollment address was not significant in our model and did not alter our results. In addition, increasing the cutoff score for the 11-item CES-D or using categorical outcomes for fear of violence did not change the magnitude or direction of our results, although some statistical power was lost (data not shown). Social support was not related to awareness, victimization, fear of neighborhood violence, or caregiver depression. Further, we found no change in the direction or magnitude of our results when measures of social support were included in the multilevel model (data not shown).
Caregivers of children without asthma
Although our primary objective was to test the effects of neighborhood violence among caregivers of children with a chronic illness, we repeated our analysis among caregivers of children without asthma (control group). Multivariate results were in the same direction and quantitatively similar to results from caregivers of children with asthma, although only the relationship between history of victimization and depression was significant in this population. After controlling for age, race, and failure to report income, fear of neighborhood violence increased the odds of screening positive for depression, although the finding was not significant [OR: 2.31 (95% CI: 0.96, 5.56); p = 0.063]. A history of victimization increased the odds of screening positive for depression [OR: 4.02 (95% CI: 1.67, 9.70); p = 0.02], while awareness of violent events in the neighborhood did not [OR: 0.89 (95% CI: 0.37, 2.14); p = 0.8].
This study of caregivers of children with asthma found that fear of neighborhood violence increased the risk of screening positive for depression, while awareness of neighborhood violent events did not. Victimization was associated with a possible trend towards increased risk of screening positive for depression. We found high levels of depression and experience with violence in our population; 45 of 150 caregivers (30%) in our study screened positive for depression, while about 20% of the population is expected to score at or above this level (Comstock & Helsing, 1976
). A large percentage (27%) of asthma subjects had a homicide within 500 ft of their home in 2001. Half (50%) of participants knew of a recent violent event in the neighborhood, and 21% knew of a recent murder. Nonetheless, awareness of a recent event did not increase the risk of screening positive for depression.
Few prior studies have included an objective measure of community violence in their analyses (Sampson et al., 1997
; Wright et al., 2004
). In 2001, the city of Baltimore experienced 256 homicides, many within a tenth of a mile of the front doors of our subjects. Although nearby homicide was not significant in our final model, it increased fear and awareness of neighborhood violence, as well as awareness of a neighborhood murder in our bivariate analysis. These findings suggest that asking about neighborhood violence strongly corresponds to true neighborhood events, and that community violence, not surprisingly, has concrete effects on fear of violence among adults.
Our findings have important implications for the care of inner-city children with asthma. Caregiver depression may affect ability to manage medication regimens, or to follow asthma recommendations, such as not smoking, as has been found in previous studies. For example, Bartlett et al. (2001)
reported that maternal depression increased emergency department use among children with asthma. A separate study found worsened asthma symptoms among children whose caretakers exhibited higher anxiety (Silver, Warman, & Stein, 2005
), while a study by Price, Bratton, and Klinnert found that pediatric asthma quality of life decreased with negative affect among caregivers (Price, Bratton, & Klinnert, 2002
Our results are also consistent with other studies of the effects of violence on mental health among children and adults. Kliewer, Lepore, Oskin, and Johnson (1998)
found that exposure to violence in the community of residence was significantly associated with intrusive thinking, anxiety, and depression among 8-12 year old children. A study of violence among sheltered homeless and low-income adult women found that being a victim of recent physical violence, including assault, was associated with a 2.64 times increased risk of symptoms of depression (95% CI: 1.4, 5.0) (Rayburn et al., 2005
; Sampson et al., 1997
; Wright et al., 2004
). Our findings build on prior results by specifically addressing fear and awareness of neighborhood violence as well as recent victimization.
Awareness of a recent neighborhood violent event, including murder and violent argument, did not increase the risk of feeling depressed in our study. Awareness of neighborhood events may represent strong social ties or deep-rooted links to the surrounding community. Although adjusting for measures of social support did not alter our findings, prior studies have demonstrated that social ties decrease the risk of depressive symptoms among mothers (Coiro, 2001
; Paarlberg et al., 1996
; Panzarine, Slater, & Sharps, 1995
; Small, Astbury, Brown, & Lumley, 1994
) and among spousal caregivers (Cannuscio et al., 2004
). One possible explanation is that caregivers who are aware of violent neighborhood events may have larger social networks, not effectively measured by the Medical Outcomes Study Social Support Survey, so that caregivers learn of violent events in the neighborhood, but are protected from depression by the stress-buffering effects of strong social ties (Kawachi & Berkman, 2001
Awareness of a violent event may also differ from victimization or fear of violence in that the event is psychologically more distant from the subject. Fitzpatrick found that being a victim of violence but not witnessing violent acts was associated with depression among African-American youths (Fitzpatrick, 1993
). We hypothesize that awareness of a violent event becomes important when it is psychologically translated into fear of violence; psychological distance may be one of the factors affecting this translation.
This study of neighborhood violence has a few relevant weaknesses. Since our study was conducted entirely in an urban setting, we cannot be sure if a similar effect of violence would be found in other residential settings or other countries. We have focused on the violent urban setting, however, because of the generally unexplained asthma disparities there (Sampson et al., 1997
; Wright et al., 2004
). Knowledge of one’s neighbors is generally lower in urban settings (Fischer, 1973
), and social ties with neighbors are strongest among rural residents (Geis & Ross, 1998
). Additionally, because our population is primarily African-American, we are unable to determine the independent impact of race/ethnicity on the effects of neighborhood violence in this study. Nonetheless, our findings are highly relevant to urban dwelling African-Americans, who are markedly affected by asthma in the United States (Mannino et al., 2002
). Finally, it is important to note that depression is a complex and multifactorial illness. While we tested for the contribution of social support and other demographic factors, we were unable to include such potential contributors as stressful life events or substance use as they were not measured in our questionnaire.
In conclusion, fear of neighborhood violence increased the risk of screening positive for depression, while history of victimization was associated with a possible trend towards screening positive for depression, in this population of primarily African-American caregivers of children with asthma. Awareness of a recent violent event in the neighborhood, which may indicate strong social ties and knowledge of community events, did not increase the risk of screening positive for depression. Our findings suggest the personal experience of violence in or around the home can have a profound psychological impact on caregivers, which, based the results of prior studies, may interfere with the needed care of young children with asthma. Health care providers of urban children with asthma should be aware of these possible deleterious effects of neighborhood violence and consider asking caregivers about their own experiences, and making referrals for screening and management of caregiver depression.