This study explored whether differences exist between Latino and non–Latino white children with asthma in their pulmonary function perception ability and how these differences relate to asthma morbidity. In a large and carefully evaluated sample we found that older age, male sex, less poverty, greater cognitive ability, and a tendency to report more general somatic symptoms were associated with better perceptual accuracy. Controlling for these covariates, non–Latino white children were more accurate perceivers than Latino children, whose inaccuracy was primarily in the direction of overperception of minimal actual compromise. Among the Latinos, those living in Rhode Island (Puerto Ricans and Dominicans) were more accurate than island Puerto Ricans. Use of inhaled corticosteroids was not found to be related to any aspect of pulmonary function perception in this sample, despite several reports to the contrary in small studies of adults with severe asthma (37
Motivated by an interest in understanding the factors behind the well-documented ethnic disparities in pediatric asthma, this study is the first to demonstrate clear differences in pulmonary function perceptual ability between Latino and NLW children with asthma. For the entire sample, accurate perception consistently predicted less functional morbidity and lower health care use. Analyses of significant relationships between perceptual accuracy scores and asthma outcomes by ethnic group did not yield a meaningful pattern of results, likely due to a combination of reduced power, a relatively large number of analyses, and the multiple factors associated with the different health care systems (22
It is important to note in interpreting these results that the three perceptual accuracy scores are not independent; for each child the three scores add up to 100%. Thus, if a child is inaccurate in either the danger zone or the magnification zone, the percentage of points in the accurate zone will necessarily be lower. For the Latino children, their inaccuracy tended to be in the direction of magnification: compared with their NLW counterparts, they more often subjectively reported that they felt more compromised than their objective lung function indicated. Because functional morbidity involves substantial subjectivity in the reporting and entails no professional involvement (unlike, e.g., hospitalization), functional morbidity might be expected to be more strongly related to high sensitivity to physical symptoms than health care use variables.
The fact that boys were overall more accurate than girls in perceiving their asthma symptoms is noteworthy, especially in light of research showing that airway hyperreactivity decreases after puberty in boys but not in girls (39
). In our large, multiethnic sample, boys less than 11 years of age had, on average, 57% of their points in the accurate zone compared with 70% for boys more than 11 years of age. In contrast, the mean accurate zone score of 52% for younger girls was quite comparable to the 58% score for girls more than 11 years of age. The RIPRAC protocol did not systematically assess airway hyperresponsiveness, but these data suggest a possible inverse relationship between hyperresponsiveness and symptom perception ability.
The relationship between recognized asthma disparities and perceptual ability in the Latino population is likely bidirectional. In this study, the magnification scores of Latinos paralleled the reported rates of asthma morbidity and mortality (40
): highest among island Puerto Ricans, next highest among Puerto Ricans and Dominicans living in Rhode Island, and substantially lower among NLWs. The personal familiarity of patients and families with individuals who had near-death or fatal asthma episodes—relatively common in Puerto Rico—would likely increase oversensitivity to even mild asthma symptoms, which could result in higher magnification scores.
Conditioning effects on perceptual accuracy are possible over time given the chronic nature of asthma, and patients are vulnerable to overperception of familiar symptoms (41
). If there is differential access to asthma health care for Latinos compared with NLWs, similar to what has been documented in the administration of analgesics (42
), Latinos would reasonably expect to have less access except when their compromise is severe. Magnification of minor degrees of compromise might thus be reinforced by anxious families who are worried that their child might otherwise not receive care they believe to be needed.
Conversely, to the degree that greater symptom magnification by Latinos leads to higher ED use, unscheduled office visits, hospitalizations, and illness behavior, the tendency toward magnification could be viewed as a cause of asthma disparities rather than a result.
Several limitations of this study should be noted. The relationships between perceptual accuracy, ethnicity, and asthma morbidity were statistically significant—sometimes highly so—but the relationships were modest. This pattern is common in behavioral research, in which the typical effect size accounts for approximately 9% of variance. Despite having the majority of variance unexplained, understanding a small component of a complex behavioral phenomenon can help unravel some of the explanatory pathways. Interpretation must take place in the context of other important factors at the biological, environmental, individual and family, cultural, and health care system levels that impact both perceptual ability and asthma morbidity (14
). The subjects, although thoroughly evaluated and large in number, came from a convenience sample in both Rhode Island and Puerto Rico, with some biases noted between those who were included in the analyses and those who were excluded, and thus these results cannot be extrapolated to the population as a whole. The Latinos in this sample were intentionally limited to Caribbean groups (Dominicans and Puerto Ricans), and findings may not apply to other Latinos, such as Mexicans, who have different patterns of asthma prevalence and presentation (40