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1.  Ethnic Differences in Somatic Symptom Reporting in Children With Asthma and Their Parents 
Objectives
The purpose of this study is to examine the association between child and parent somatic symptom reporting and pediatric asthma morbidity in Latino and non-Latino white children.
Method
The study consists of 786 children, 7 to 15 years of age, in Rhode Island (RI) and Puerto Rico. Children’s and parents’ levels of general somatic symptoms were assessed with well-established self-report measures. Clinician-determined asthma severity was based on reported medication use, asthma symptom history, and spirometry results. Asthma-related health care use and functional morbidity was obtained via parent self-report.
Results
Child and parent reports of general somatic symptoms were significantly related to pediatric asthma functional morbidity when controlling for poverty, parent education, child’s age, and asthma severity. In controlling for covariates, Latino children in RI reported higher levels of somatic symptoms than Island Puerto Rican children, and RI Latino parents reported more somatic symptoms than RI non-Latino white parents (p < .05).
Conclusions
This study replicates and extends to children in previous research showing higher levels of symptom reporting in Latinos relative to whites. Results also provide new insight into the relation between general somatic symptom reports and pediatric asthma. Ethnic differences in somatic symptom reporting may be an important factor underlying asthma disparities between Latino and non-Latino white children.
doi:10.1097/CHI.0b013e3181a81333
PMCID: PMC3278967  PMID: 19564802
asthma; health disparities; somatization
2.  Ethnic Differences in Caregiver Quality of Life in Pediatric Asthma 
Objective
The aim of this study was to determine ethnic and site differences in quality of life (QOL) in a sample of Latino (Puerto Rican and Dominican) and non-Latino White (NLW) caregivers of children with asthma in mainland US and Island PR. We also investigated ethnic and site differences in associations between caregiver QOL and indicators of asthma morbidity.
Method
Seven-hundred and eighty-seven children with asthma (7–16 years of age) and their primary caregivers participated. Primary caregivers completed a measure of QOL, child asthma control, and emergency department utilization, among other measures.
Results
Ethnic and site differences were found on total QOL scores (ΔF(1, 783) = 29.46, p < .001). Island PR caregivers reported worse QOL scores than RI Latino and NLW caregivers; RI Latino caregivers reported significantly worse QOL scores than NLW caregivers. In RI Latino and Island PR children, worse caregiver QOL was associated with asthma that was not in control and with 1 or more ED visits.
Conclusion
Latino caregivers may be experiencing a greater level of burden related to their child’s asthma than NLW caregivers. Caregiver QOL in pediatric asthma may be a reflection of broader, contextual stress that some Latino caregivers experience on a daily basis (e.g., cultural beliefs, acculturation). Future research should continue to investigate mechanisms that explain the burden associated with pediatric asthma in Latino families, as well as whether QOL assessments should consider the impact of everyday stressors on caregiver QOL in pediatric asthma.
doi:10.1097/DBP.0b013e318264c2b7
PMCID: PMC3463809  PMID: 23027132
pediatric asthma; quality of life; caregivers; disparities; ethnicity
3.  Access to and Use of Asthma Health Services Among Latino Children: The Rhode Island-Puerto Rico Asthma Center Study 
Medical Care Research and Review  2011;68(6):683-698.
This study determines asthma-related health care access and utilization patterns for Latino children of Puerto Rican and Dominican origin residing in Rhode Island (RI) and Latino children residing in Puerto Rico (Island). Data included 804 families of children with persistent asthma recruited from clinics. Island children were less likely to receive regular asthma care and care from a consistent provider and more likely to have been to the emergency department and hospitalized for asthma than RI children. Island children were 2.33 times more likely to have used the emergency department for asthma compared with RI non-Latino White (NLW) children. Latino children residing in both Island and RI were less likely to have used specialty care and more likely to have had a physician visit for asthma in the past year than RI NLW children. The differences might reflect the effects of the different delivery systems on pediatric health care utilization and asthma management.
doi:10.1177/1077558711404434
PMCID: PMC3266228  PMID: 21536604
asthma; Hispanic Americans; Latino; children; health service accessibility; health care utilization; Puerto Rico
4.  Issues and Methods in Disparities Research 
Pediatric Pulmonology  2009;44(9):899-908.
Summary
Background
Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research.
Objectives and Methods
This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island–Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research.
Results
Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented.
Conclusions
Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them.
doi:10.1002/ppul.21075
PMCID: PMC3266230  PMID: 19658111
asthma; health disparities; Latino; Puerto Rican; children; research methods
5.  Medication Adherence Among Latino and Non-Latino White Children With Asthma 
Pediatrics  2012;129(6):e1404-e1410.
OBJECTIVE:
Latino children of Caribbean descent remain at high risk for poorly controlled asthma. Controller medications improve asthma control; however, medication adherence remains suboptimal, particularly among minorities. This study assessed socioeconomic, family-based, and parent factors in medication adherence among children with asthma from Rhode Island (RI; Latino and non-Latino white [NLW]) and Puerto Rico.
METHODS:
Data collection occurred as part of a multicenter study of asthma disparities. Our sample included children (ages 7–16) prescribed objectively monitored controller medications (n = 277; 80 island Puerto Rico, 114 RI Latino, 83 RI NLW). Parents completed questionnaires regarding family background and beliefs about medications. Families participated in an interview regarding asthma management. Multilevel analyses (maximum likelihood estimates) accounting for children being nested within site and ethnic group assessed the contribution of social context, family, and parent variables to medication adherence.
RESULTS:
Medication adherence differed by ethnic group (F2, 271 = 7.46, P < .01), with NLW families demonstrating the highest levels of adherence. Multilevel models indicated that parental beliefs about medication necessity and family organization regarding medication use were significant predictors of adherence, even for families below the poverty threshold. With family factors in the model, a substantial improvement in model fit occurred (Akaike Information Criterion change of 103.45).
CONCLUSIONS:
Adherence to controller medications was lower among Latino children in our sample. Targeted interventions that capitalize on existing family resources, emphasize structure, and address parental beliefs about the importance of medications may be of benefit to families from different cultural backgrounds.
doi:10.1542/peds.2011-1391
PMCID: PMC3362901  PMID: 22566417
asthma; patient nonadherence; disparities
6.  Beliefs and Barriers to Medication Use in Parents of Latino Children With Asthma 
Pediatric Pulmonology  2009;44(9):892-898.
Summary
Objective
Disparities in asthma outcomes exist between Latino and non-Latino white (NLW) children. We examined rates of medication use, medication beliefs, and perceived barriers to obtaining medication in US and island Puerto Rican parents of children with asthma
Hypotheses
Island PR parents would report the lowest rates of controller medication use, followed by RI Latino and RI NLW parents; Latino parents would report more medication concerns than NLW parents; and Island PR parents would report the most barriers to medication use.
Study Design
Five hundred thirty families of children with persistent asthma participated, including 231 Island PR, 111 RI NLW, and 188 RI Latino. Parents completed survey measures.
Results
Group differences were found on reported use of ICS (X2 = 50.96, P <0.001), any controller medication (X2 = 56.49, P <0.001), and oral steroids (X2 = 10.87, P <0.01). Island PR parents reported a greater frequency of barriers to medication use than the other two groups (X2 = 61.13, P <0.001). Latino parents in both sites expressed more medication concerns than NLW parents (F = 20.18, P <0.001). Medication necessity was associated with ICS use in all three groups (all P’s <0.01). Medication concerns were positively associated with ICS use in PR only (OR = 1.64, P <0.05).
Conclusions
Differences in medication beliefs and the ability to obtain medications may explain the reported disparity in controller medication use. Further studies are needed to evaluate these obstacles to medication use.
doi:10.1002/ppul.21074
PMCID: PMC3266229  PMID: 19672958
disparities; adherence; asthma; ethnicity; childhood; medication use
7.  Cultural-Related, Contextual, and Asthma-Specific Risks Associated with Asthma Morbidity in Urban Children 
The objective of this study was to examine associations between specific dimensions of the multidimensional cumulative risk index (CRI) and asthma morbidity in urban, school-aged children from African American, Latino and Non-Latino White backgrounds. An additional goal of the study was to identify the proportion of families that qualify for high-risk status on each dimension of the CRI by ethnic group. A total of 264 children with asthma, ages 7–15 (40% female; 76% ethnic minority) and their primary caregivers completed interview-based questionnaires assessing cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of asthma-related risks were associated with more functional morbidity for all groups of children, despite ethnic group background. Contextual and cultural risk dimensions contributed to more morbidity for African-American and Latino children. Analyses by Latino ethnic subgroup revealed that contextual and cultural risks are significantly related to more functional morbidity for Puerto Rican children compared to Dominican children. Findings suggest which type of risks may more meaningfully contribute to variations in asthma morbidity for children from specific ethnic groups. These results can inform culturally sensitive clinical interventions for urban children with asthma whose health outcomes lag far behind their non-Latino White counterparts.
doi:10.1007/s10880-009-9178-3
PMCID: PMC3266227  PMID: 20157798
Pediatric asthma; Cumulative risks; Ethnic minority; Urban
8.  Differences in Environmental Control and Asthma Outcomes Among Urban Latino, African American, and Non–Latino White Families 
Latino and African American children with asthma are at increased risk for asthma morbidity compared with non–Latino White children. Environmental control (ie, environmental exposures and family strategies to control them) may contribute to greater asthma morbidity for ethnic minority children living in urban environments. This study examined ethnic differences in a semi-structured assessment of environmental control, associations between environmental control and asthma outcomes (asthma control, functional limitation, and emergency department [ED] use), and ethnic differences in environmental triggers in a sample of urban Latino, African American, and non–Latino White families. One hundred thirty-three children (6–13 years of age) and their caregivers completed demographic questionnaires, measures of asthma control and morbidity, and a semi-structured interview assessing environmental control. Reported environmental control differed significantly by ethnicity (P<0.05), with Latino families reporting higher levels of environmental control. Reported environmental control was significantly associated with asthma control (P<0.017) and functional limitation (P<0.017). Reported environmental control and ED use were significantly associated in Latino families (P<0.05). Non–Latino White and African American families reported more secondhand smoke exposure than Latino families (P<0.001). Latino families reported more optimal home environmental control than other ethnic groups. Substantial ethnic differences in asthma triggers suggest that observed ethnic disparities in asthma may be due, at least in part, to differences in the home environment.
doi:10.1089/ped.2011.0081
PMCID: PMC3255502  PMID: 22276226
9.  Racial/Ethnic Variation in Parent Perceptions of Asthma 
Objective
Black and Latino children with asthma have worse morbidity and receive less controller medication than their white peers. Scant information exists on racial/ethnic differences in parent perceptions of asthma. To compare parent perceptions among black, Latino, and white children with asthma in 4 domains: (1) expectations for functioning with asthma; (2) concerns about medications; (3) interactions with providers; and (4) competing family priorities.
Methods
In this cross-sectional study, we conducted telephone interviews with parents of children with persistent asthma in a Medicaid health plan and a multispecialty provider group in Massachusetts. To measure expectations for functioning and other domains, we adapted multi-item scales from past studies. Associations between race/ethnicity and these domains were evaluated in multivariate analyses that controlled for age, gender, household income, parental education, insurance, and language. The response rate was 72%.
Results
Of the 739 study children, 24% were black, 21% Latino, and 43% white. Parents of black and Latino children had lower expectations for their children’s functioning with asthma (P < .001), higher levels of worry about their children’s asthma (P < .001), and more competing family priorities (P = 004) compared with parents of white children. Parents of Latino children had higher levels of concern about medications for asthma than parents of black or white children (P = 002). There were no differences among racial/ethnic groups in reports of interactions with the provider of their children’s asthma care.
Conclusions
Efforts to eliminate disparities in childhood asthma may need to address variation in expectations and competing priorities between minority and white families.
doi:10.1016/j.ambp.2007.10.007
PMCID: PMC3614412  PMID: 18355737
asthma; health care disparities; racial/ethnic variation
10.  Conundrums in childhood asthma severity, control, and health care use: Puerto Rico versus Rhode Island 
Background
The lifetime prevalence of self-reported asthma among Puerto Ricans is very high, with increased asthma hospitalizations, emergency department visits, and mortality rates. Differences in asthma severity between the mainland and island, however, remain largely unknown.
Objective
We sought to characterize differences in asthma severity and control among 4 groups: (1) Island Puerto Ricans, (2) Rhode Island (RI) Puerto Ricans, (3) RI Dominicans, and (4) RI whites.
Methods
Eight hundred five children aged 7 to 15 years completed a diagnostic clinic session, including a formal interview, physical examination, spirometry, and allergy testing. Using a visual grid adapted from the Global Initiative for Asthma, asthma specialists practicing in each site determined an asthma severity rating. A corresponding level of asthma control was determined by using a computer algorithm.
Results
Island Puerto Ricans had significantly milder asthma severity compared with RI Puerto Ricans, Dominicans, and whites (P < .001). Island Puerto Ricans were not significantly different from RI whites in asthma control. RI Puerto Ricans showed a trend toward less control compared with island Puerto Ricans (P = .061). RI Dominicans had the lowest rate of controlled asthma. Paradoxically, island Puerto Ricans had more emergency department visits in the past 12 months (P < .001) compared with the 3 RI groups.
Conclusions
Potential explanations for the paradoxic finding of milder asthma in island Puerto Ricans in the face of high health care use are discussed. Difficulties in determining guideline-based composite ratings for severity versus control are explored in the context of disparate groups.
doi:10.1016/j.jaci.2009.05.014
PMCID: PMC3380616  PMID: 19615729
Asthma; severity; control; clinical guidelines; Global Initiative for Asthma; Latino; Puerto Rican; Dominican; Rhode Island; health care use
11.  Latino Caregivers' Beliefs about Asthma: Causes, Symptoms, and Practices 
Background and Objective:
This study examined belief systems of Latino caregivers who have children with asthma from Puerto Rican and Dominican backgrounds who resided on the Island of PR and the Mainland. The goal of this study was to document similarities and differences in beliefs about the causes, symptoms and treatments of asthma across two sites and two Latino ethnic sub-groups of children who remain the most at risk for asthma morbidity.
Methods:
Participants included 100 primary caregivers of a child with asthma. Fifty caregivers from Island PR and fifty caregivers from mainland RI were interviewed (at each site, 25 caregivers were from Puerto Rican backgrounds and 25 caregivers were from Dominican backgrounds). The interview included an assessment of demographic information and beliefs about the causes and symptoms of asthma, and asthma practices.
Results:
Results indicated more similarities in beliefs about the causes and symptoms of asthma across site and ethnic group. The majority of differences were among beliefs about asthma practices by site and ethnic group. For example, a higher proportion of caregivers from Island PR, particularly those of Dominican descent, endorsed that a range of home and botanical remedies are effective for treating asthma.
Conclusions:
Results from this study point to several interesting directions for future research including larger samples of Latino caregivers with children who have asthma. A discussion of the importance of understanding cultural beliefs about asthma and asthma practices is also reviewed.
doi:10.1080/02770900801890422
PMCID: PMC2590764  PMID: 18415827
Asthma; Latino Caregiver's Beliefs
12.  Missed sleep and asthma morbidity in urban children 
Background
Children living in urban environments have many risk factors for disrupted sleep, including environmental disturbances, stressors related to ethnic minority status, and higher rates of stress and anxiety. Asthma can further disrupt sleep in children, but little research has examined the effects of missed sleep on asthma morbidity.
Objective
To examine the associations among missed sleep, asthma-related quality of life (QoL), and indicators of asthma morbidity in urban children with asthma from Latino, African American, and non-Latino white backgrounds. Given the importance of anxiety as a trigger for asthma symptoms and the link between anxiety and disrupted sleep, the associations among anxiety, asthma morbidity indicators, and missed sleep were also tested.
Methods
Parents of 147 children ages 6 to 13 years completed measures of asthma morbidity and missed sleep, parental QoL, and child behavior.
Results
Higher reports of missed sleep were related to more frequent school absences, more activity limitations, and lower QoL across the sample. The associations between missed sleep and asthma morbidity were stronger for Latino children compared with non-Latino white and African American children. For children with higher anxiety, the associations between missed sleep and asthma morbidity were stronger than for children with lower anxiety.
Conclusion
Results offer preliminary support for missed sleep as a contributor to daily functioning of children with asthma in urban neighborhoods. Missed sleep may be more relevant to Latino families. Furthermore, anxiety may serve as a link between sleep and asthma morbidity because higher anxiety may exacerbate the effects of disrupted sleep on asthma.
doi:10.1016/j.anai.2012.05.015
PMCID: PMC3426919  PMID: 22727156
13.  Elevated asthma morbidity in Puerto Rican children: a review of possible risk and prognostic factors. 
Western Journal of Medicine  1999;170(2):75-84.
Latino children represent a significant proportion of all US children, and asthma is the most common chronic illness affecting them. Previous research has revealed surprising differences in health among Latino children with asthma of varying countries of family origin. For instance, Puerto Rican children have a higher prevalence of asthma than Mexican American or Cuban American children. In addition, there are important differences in family structure and socioeconomic status among these Latino populations: Cuban Americans have higher levels of education and family income than Mexican-Americans and Puerto Ricans; mainland Puerto Rican children have the highest proportion of households led by a single mother. Our review of past research documents differences in asthma outcomes among Latino children and identifies the possible genetic, environmental, and health care factors associated with these differences. Based on this review, we propose research studies designed to differentiate between mutable and immutable risk and prognostic factors. We also propose that the sociocultural milieus of Latino subgroups of different ethnic and geographic origin are associated with varying patterns of risk factors that in turn lead to different morbidity patterns. Our analysis provides a blue-print for future research, policy development, and the evaluation of multifactorial interventions involving the collaboration of multiple social sectors, such as health care, public health, education, and public and private agencies.
PMCID: PMC1305446  PMID: 10063393
14.  Using colorectal trends in the U.S. to identify unmet primary care needs of vulnerable populations 
Preventive medicine  2012;55(2):131-136.
Background
Colorectal cancer screening (CRC) disparities have worsened in recent years.
Objective
To examine progress toward Healthy People 2010 goals for CRC screening among ethnic/racial groups, including disaggregated Latino groups.
Methods
Multivariate logistic regressions examined associations between ethnicity/race and primary outcomes of self-reported guideline-concordant CRC screenings considering time trends for 65,947 respondents of the Medical Expenditure Panel Survey from 2000–2007 age 50-years and older from six groups (non-Latino White, non-Latino Black, Puerto Rican, Cuban, Mexican, and Other Latino). We also tested for modification effects by education, income, and health insurance.
Results
Most groups approached Healthy People 2010 CRC screening rate goals, including non-Latino Whites (47%), non-Latino Blacks (42%) and Puerto Ricans (40%), while Mexicans remained disparately lower (28%). Higher education, income and insurance coverage, partially attenuated this lower likelihood, but Mexican rates remained significantly lower than non-Latino Whites for receiving endoscopy in the past 5 years {OR(95% CI) =0.68(0.59–0.77)} and having received any CRC screening {0.70(0.62–0.79)}.
Conclusions
Among ethnic/racial groups examined, only Mexicans met healthcare disparity criteria in CRC screening. Findings suggest that healthcare equity goals can be attained if resources affecting continuity of care or ability to pay for preventive services are available, and targeted populations are adequately identified.
doi:10.1016/j.ypmed.2012.05.016
PMCID: PMC3786063  PMID: 22659226
15.  Perceptual accuracy of upper airway compromise in children: Clinical relevance and future directions for research 
Allergy & Rhinology  2013;4(2):e54-e62.
Approximately 80% of children with asthma have coexisting allergic rhinitis. The accurate recognition and assessment of asthma and rhinitis symptoms is an integral component of guideline-based treatment for both conditions. This article describes the development and preliminary evaluation of a novel paradigm for testing the accuracy of children's assessment of their upper airway (rhinitis) symptoms. This work is guided by our previous research showing the clinical efficacy of tools to evaluate children's perceptual accuracy of asthma symptoms and linking accurate asthma symptom perception to decreased asthma morbidity (Fritz G, et al., Ethnic differences in perception of lung function: A factor in pediatric asthma disparities? Am J Respir Crit Care Med 182:12–18, 2010; Klein RB, et al., The Asthma Risk Grid: Clinical interpretation of symptom perception, Allergy Asthma Proc 251–256, 2004). The pilot study tests a paradigm that allows for the examination of the correspondence of children's assessment of their upper airway functioning with actual values of upper airway flow through the use of a portable, handheld nasal peak flowmeter. Nine children with persistent asthma were evaluated over a 4-week period. The article describes the rhinitis perceptual accuracy paradigm and reviews the results of a pilot study, showing a large proportion of inaccurate rhinitis symptoms “guesses” by the sample of children with persistent asthma. Patterns of inaccuracy, rhinitis control, and asthma morbidity are also described. Directions for future work are reviewed. The development of clinical tools to evaluate children's accuracy of rhinitis symptoms are needed, given the central role of the self-assessment of symptoms in guideline-based care. Accurate perception of the severity of rhinitis symptoms may enhance rhinitis control, lessen the burden of asthma, and prevent unnecessary emergency use among this high-risk group of children.
doi:10.2500/ar.2013.4.0060
PMCID: PMC3793113  PMID: 24124637
Allergy; asthma; children; perceptual accuracy; rhinitis; treatment; upper airway
16.  Pediatrician Identification of Latino Children at Risk for Autism Spectrum Disorder 
Pediatrics  2013;132(3):445-453.
BACKGROUND AND OBJECTIVES:
Latino–white disparities in age at autism spectrum disorder (ASD) diagnosis may be modified by primary care pediatrician (PCP) practices and beliefs. The objectives of this study were to assess ASD and developmental screening practices, attitudes toward ASD identification in Latino children, and barriers to ASD identification for Latino children, in a sample of 267 California PCPs.
METHODS:
In mail-based PCP survey, we assessed rates of bilingual general developmental and ASD screening, perceptions of parent ASD knowledge in Latino and white families, reports of difficulty assessing for ASDs in Latino and white children, and perceptions of barriers to early ASD identification for Latinos.
RESULTS:
Although 81% of PCPs offered some form of developmental screening, 29% of PCPs offered Spanish ASD screening per American Academy of Pediatrics guidelines, and only 10% offered both Spanish general developmental and Spanish ASD screening per American Academy of Pediatrics guidelines. Most PCPs thought that Latino (English and Spanish primary family language) parents were less knowledgeable about ASDs than white parents. PCPs had more difficulty assessing ASD risk for Latino children with Spanish primary family language than for white children, even when the PCP conducted recommended ASD screening or had >25% Latino patients. The most frequent barrier to ASD identification in Latinos was access to developmental specialists.
CONCLUSIONS:
Multiple factors in the primary care setting may contribute to delayed ASD identification for Latinos. Promoting language-appropriate screening, disseminating culturally appropriate ASD materials to Latino families, improving the specialist workforce, and providing PCP support in screening and referral of Latino children may be important ways to reduce racial and ethnic differences in care.
doi:10.1542/peds.2013-0383
PMCID: PMC3876760  PMID: 23958770
autism spectrum disorder; Hispanic Americans; pediatrics; health care disparities; child development; developmental disabilities; developmental screening
17.  Identifying Individual, Cultural and Asthma-Related Risk and Protective Factors Associated With Resilient Asthma Outcomes in Urban Children and Families 
Journal of Pediatric Psychology  2012;37(4):424-437.
Objective The goal of this study is to identify individual, family/cultural, and illness-related protective factors that may minimize asthma morbidity in the context of multiple urban risks in a sample of inner-city children and families. Methods Participating families are from African-American (33), Latino (51) and non-Latino white (47) backgrounds. A total of 131 children with asthma (56% male), ages 6–13 years and their primary caregivers were included. Results Analyses supported the relationship between cumulative risks and asthma morbidity across children of the sample. Protective processes functioned differently by ethnic group. For example, Latino families exhibited higher levels of family connectedness, and this was associated with lower levels of functional limitation due to asthma, in the context of risks. Conclusions This study demonstrates the utility of examining multilevel protective processes that may guard against urban risks factors to decrease morbidity. Intervention programs for families from specific ethnic groups can be tailored to consider individual, family-based/cultural and illness-related supports that decrease stress and enhance aspects of asthma treatment.
doi:10.1093/jpepsy/jss002
PMCID: PMC3415979  PMID: 22408053
asthma outcomes; cultural factors; inner city; pediatric asthma; protective factors
18.  Health Status, Activity Limitations, and Disability in Work and Housework Among Latinos and Non-Latinos With Arthritis: An Analysis of National Data 
Arthritis and rheumatism  2006;55(3):442-450.
Objective
To document disparities in health status, activity limitations, and disability in work and housework between Latinos and non-Latino whites with arthritis. We examined whether sociodemographic factors (age, income, and education) account for the disparities between the ethnic groups, and whether comorbid conditions, disease duration, health care utilization, and functional abilities predict health status, activity limitations, and work and housework disability after controlling for sociodemographic variables.
Methods
We analyzed data from the Condition file of the 1994 National Health Interview Survey on Disability, Phase I.
Results
The risk of worse health, activity limitations, and work and housework disability was >2 times greater among Latinos compared with non-Latino whites. In the regression models accounting for potential confounders, Latino ethnicity remained significantly associated with poorer health status, but not activity limitations or disability in work or housekeeping. Of the socioeconomic status variables, education had a significant protective effect on work disability and health status. Comorbid conditions and health care utilization increased the likelihood of worse health, activity limitations, and work disability. Limitations in physical function were associated with poorer health and disability in work and homemaking.
Conclusion
Social status differences between Latinos and non-Latinos may account for disparities in activity limitations and disability in work and housework. Education may provide various health benefits, including access to a range of occupations that do not require physical demands. The findings help to address the great gap in knowledge concerning factors related to the health and disability status of Latinos with arthritis.
doi:10.1002/art.21981
PMCID: PMC3606810  PMID: 16739212
Latinos; Hispanics; Limitations; Work disability; Housework disability
19.  An Investigation of Racial and Ethnic Disparities in Service Utilization among Homeless Adults with Severe Mental Illness 
Objective
To determine if service disparities exist among severely mentally ill homeless adults, a vulnerable population with a high level of unmet need.
Methods
This study used data collected at baseline for 6,829 black, Latino, and non-Latino white participants in the Access to Community Care and Effective Services and Support study. Outcome variables were measures of utilization of psychiatric outpatient, housing, and case management services in the previous 60 days. The sample was divided into white/black and white/Latino cohorts. Within each cohort, participants were stratified into comparable groups using propensity scores that estimated log-odds of being black or Latino as a function of several confounding variables. White minus black/Latino differences in mean number of visits (a measure of intensity) and in the mean probability of at least 1 visit (a measure of access) were subsequently estimated.
Results
The study sample consisted of 50% black, 6% Latino, and 44% white participants. Service utilization was low for the three services regardless of race/ethnicity. On multivariate analyses of service utilization in the previous 60 days, blacks had fewer psychiatric outpatient visits than whites (mean difference [95% CI] = 0.46 [0.10, 0.81]) yet Latinos had more case management visits than whites (mean difference [95% CI] = −0.51 [−1.03, −0.05]). Access analyses did not reveal disparities.
Conclusions
While blacks have lower intensity of psychiatric outpatient utilization than whites hence experiencing a service disparity, Latinos have higher intensity of case management utilization than whites. Possible contributors and clinical and methodological implications of these results are discussed.
doi:10.1176/appi.ps.60.8.1032
PMCID: PMC2898183  PMID: 19648189
20.  Prevalence of mental illness in immigrant and non-immigrant U.S. Latino groups 
The American journal of psychiatry  2008;165(3):359-369.
Objective
Although widely reported among Latinos, contradictory evidence exists regarding the generalizability of the immigrant paradox; that foreign nativity is protective against psychiatric disorders. We examine whether this paradox applies to all Latino groups by contrasting estimates of lifetime psychiatric disorders among Latino immigrants, Latino U.S-born, and non-Latino whites.
Method
Data from the National Latino and Asian American Study and the National Comorbidity Survey Replication represent some of the largest nationally-representative samples with psychiatric information.
Results
In aggregate, Latinos are at lower risk of most psychiatric disorders compared to non-Latinos whites and, consistent with the immigrant paradox, U.S.-born Latinos report higher rates for most psychiatric disorders than Latino immigrants. However, rates vary when data are stratified by nativity and disorder and adjusted by demographic and socioeconomic differences across groups. Among Mexicans, the immigrant paradox consistently holds across mood, anxiety and substance disorders while it is only evident among Cubans and Other Latinos for substance disorders. No differences were found in lifetime prevalence rates between migrant and U.S.-born Puerto Ricans.
Conclusions
Caution should be exercised in generalizing the immigrant paradox to all Latinos and for all psychiatric disorders. Aggregating Latinos into a single group masks great variability in lifetime risk for psychiatric disorders, with some subgroups, like Puerto Ricans, suffering from psychiatric disorders at rates comparable to non-Latino whites. Our findings thus suggest that the protective context in which immigrants lived in their country of origin possibly inoculated them against risk for substance disorders, particularly if they immigrated as adults.
doi:10.1176/appi.ajp.2007.07040704
PMCID: PMC2712949  PMID: 18245178
21.  Puerto Rican Early Adolescents’ Self-Esteem Patterns 
This study examines self-esteem as a multidimensional construct in 1 Latino subgroup, Puerto Rican girls and boys during early adolescence, using Harter’s (1985b) Self-Perception Profile for Children. The results show that in its English and Spanish versions—the latter developed by the present research team—the Self-Perception Profile for Children has adequate reliability for use with 13- to 14-year-old Puerto Rican youth living on the mainland. Results obtained in this study of Puerto Rican early adolescents, which contrasts with the results from the combined data of “Hispanics” in the American Association of University Women (1991) survey of 3,000 youth, strongly suggests that Latino subgroups need to be studied separately. The mean levels of self-esteem found among Puerto Rican girls and boys were generally similar to those found among Harter’s sample of predominantly Anglo middle school students from the suburbs of Denver except that Puerto Rican youth did not show gender differences in overall self-esteem. Gender differences in mean levels of self-esteem in different domains were similar to those of Anglo youth, regardless of the Puerto Rican youth’s individual level of psychological or behavioral acculturation. When differences by acculturation emerged, psychological acculturation appeared to play a more protective role for girls (Hispanic- or Latino-oriented girls reported being better behaved and having greater confidence in their scholastic abilities) and behavioral acculturation operated as a risk factor for boys (boys with preference for English reported low Behavioral Conduct and Scholastic Competence scores). On the other hand, greater acculturation (both psychological and behavioral) was associated with girls’ lower confidence in their physical attractiveness. Finally, the structure of self-esteem varied by gender, and psychological and behavioral acculturation.
doi:10.1207/SJRA1003_6
PMCID: PMC3066011  PMID: 21461183
22.  Dissecting Complex Diseases in Complex Populations 
Asthma is a common but complex respiratory ailment; current data indicate that interaction of genetic and environmental factors lead to its clinical expression. In the United States, asthma prevalence, morbidity, and mortality vary widely among different Latino ethnic groups. The prevalence of asthma is highest in Puerto Ricans, intermediate in Dominicans and Cubans, and lowest in Mexicans and Central Americans. Independently, known socioeconomic, environmental, and genetic differences do not fully account for this observation. One potential explanation is that there may be unique and ethnic-specific gene–environment interactions that can differentially modify risk for asthma in Latino ethnic groups. These gene–environment interactions can be tested using genetic ancestry as a surrogate for genetic risk factors. Latinos are admixed and share varying proportions of African, Native American, and European ancestry. Most Latinos are unaware of their precise ancestry and report their ancestry based on the national origin of their family and their physical appearance. The unavailability of precise ancestry and the genetic complexity among Latinos may complicate asthma research studies in this population. On the other hand, precisely because of this rich mixture of ancestry, Latinos present a unique opportunity to disentangle the clinical, social, environmental, and genetic underpinnings of population differences in asthma prevalence, severity, and bronchodilator drug responsiveness.
doi:10.1513/pats.200701-029AW
PMCID: PMC2647623  PMID: 17607004
genes; environments; Latinos; Hispanics; asthma
23.  Homes of low-income minority families with asthmatic children have increased condition issues 
Allergy and Asthma Proceedings  2014;35(6):467-474.
The home is increasingly associated with asthma. It acts both as a reservoir of asthma triggers and as a refuge from seasonal outdoor allergen exposure. Racial/ethnic minority families with low incomes tend to reside in neighborhoods with low housing quality. These families also have higher rates of asthma. This study explores the hypothesis that black and Latino urban households with asthmatic children experienced more home mechanical, structural condition–related areas of concern than white households with asthmatic children. Participant families (n = 140) took part in the Kansas City Safe and Healthy Homes Program, had at least one asthmatic child, and met income qualifications of no more than 80% of local median income; many were below 50%. Families self-identified their race. Homes were assessed by environmental health professionals using a standard set of criteria and a specific set of on-site and laboratory sampling and analyses. Homes were given a score for areas of concern between 0 (best) and 53 (worst). The study population self-identified as black (46%), non-Latino white (26%), Latino (14.3%), and other (12.9%). Mean number of areas of concern were 18.7 in Latino homes, 17.8 in black homes, 13.3 in other homes, and 13.2 in white homes. Latino and black homes had significantly more areas of concern. White families were also more likely to be in the upper portion of the income. In this set of 140 low-income homes with an asthmatic child, households of minority individuals had more areas of condition concerns and generally lower income than other families.
doi:10.2500/aap.2014.35.3792
PMCID: PMC4210655  PMID: 25584914
Air quality; allergens; asthma triggers; children; environment; Healthy Homes Program; housing quality; low-income; minority; urban
24.  Immigration and Acculturation-Related Factors and Asthma Morbidity in Latino Children* 
Journal of Pediatric Psychology  2011;36(10):1130-1143.
Objective This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described. Methods Latino children with asthma (n = 232), ages 7–16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity. Results The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S. Conclusion Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.
doi:10.1093/jpepsy/jsr041
PMCID: PMC3247793  PMID: 21745811
acculturation; asthma morbidity; immigration
25.  Lower rates of emergency department injury visits among Latino children in the USA: no association with health insurance 
Injury Prevention  2006;12(4):248-252.
Background and objective
Latino children have lower rates of injury visits to emergency departments (EDs) than non‐Latino white and African American children. This study tests the hypothesis that this difference reflects health insurance status.
Design
Secondary analysis.
Patients/setting
Children under 19 years of age visiting EDs in the USA, sampled in the National Hospital Ambulatory Medical Care Survey of EDs (NHAMCS‐ED) from 1997 to 2001.
Main outcome measures
Rates of ED injury visits; ED injury visit rates by race/ethnicity stratified by health insurance and adjusted for other covariates; subtypes of injury visits; and procedures and hospital admissions by race/ethnicity.
Results
Injuries accounted for >56 million, or 40.5%, of total ED visits among pediatric patients. Injury visits occurred at lower rates for Latino children (9.9 per 100 person years) than non‐Latino white and African American children (16.2 and 18.3, respectively), although total ED visit rates were similar. Regardless of health insurance status, Latino children had lower rates of injury visits than non‐Latino white and African American children. Latino children had lower rates of the three major subtypes of injury visits (sports, accidental falls, struck by/between objects). Latino children had similar rates of procedures and hospital admissions to non‐Latino white children.
Conclusions
Irrespective of their insurance status, Latino children have lower rates of ED injury visits in the USA than non‐Latino white children. Possible reasons for this difference include different healthcare seeking behavior or different injury patterns by race/ethnicity, but not differences in health insurance status or barriers to accessing ED care.
doi:10.1136/ip.2006.011593
PMCID: PMC2586778  PMID: 16887947
child; ethnicity; health insurance; emergency department visits

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