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1.  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
2.  The Home Environment and Family Asthma Management Among Ethnically Diverse Urban Youth with Asthma 
While the pediatric psychology literature underscores the importance of illness related aspects of the home environment for optimal family asthma management, little is known about the contribution of more global aspects of the home environment (e.g., family routines/schedule, quality of stimulation provided to child) to asthma management in ethnic minority and urban families. The goals of this study were to: 1) explore ethnic/racial group differences in global and specific dimensions of home environment quality among Latino, non-Latino white (NLW), and African American urban children with asthma; and 2) examine associations between the quality and quantity of support and stimulation within the home environment, as measured by the HOME Inventory, and family asthma management in this sample. Urban, low-income children (N=131) between the ages of 6 and 13 with asthma and a primary caregiver participated in a multi-modal assessment including an in home observation and semi structured interviews to assess aspects of home environment quality and family asthma management practices. While controlling for poverty, no ethnic group differences were found in the global home environment; however, there were significant differences in specific dimensions (e.g. Family Participation in Developmentally Stimulating Experiences, and Aspects of the Physical Environment) of home environment quality. Across the whole sample, home environment quality predicted family asthma management. When examining this association for specific ethnic groups, this finding did not hold for the Latino subsample. The results highlight the need to consider ethnic group differences in non-illness specific aspects of the home environment when addressing families’ asthma management strategies.
doi:10.1037/a0032462
PMCID: PMC3746827  PMID: 23795627
3.  Ethnic Differences in Perception of Lung Function 
Rationale: Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non–Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process.
Objectives: To determine (1) if differences exist between Latino and non–Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes.
Methods: Five hundred and twelve children, aged 7–16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use.
Measurements and Main Results: Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non–Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity.
Conclusions: Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non–Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.
doi:10.1164/rccm.200906-0836OC
PMCID: PMC2902755  PMID: 20299534
childhood asthma; symptom recognition; disparities
4.  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
5.  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
6.  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
7.  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
8.  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
9.  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
10.  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
11.  Childhood Obesity and Asthma Control in the GALA II and SAGE II Studies 
Rationale: Obesity is associated with increased asthma morbidity, lower drug responsiveness to inhaled corticosteroids, and worse asthma control. However, most prior investigations on obesity and asthma control have not focused on pediatric populations, considered environmental exposures, or included minority children.
Objectives: To examine the association between body mass index categories and asthma control among boys and girls; and whether these associations are modified by age and race/ethnicity.
Methods: Children and adolescents ages 8–19 years (n = 2,174) with asthma were recruited from the Genes-environments and Admixture in Latino Americans (GALA II) Study and the Study of African Americans, Asthma, Genes, and Environments (SAGE II). Ordinal logistic regression was used to estimate odds ratios (OR) and their confidence intervals (95% CI) for worse asthma control.
Measurements and Main Results: In adjusted analyses, boys who were obese had a 33% greater chance of having worse asthma control than their normal-weight counterparts (OR, 1.33; 95% CI, 1.04–1.71). However, for girls this association varied with race and ethnicity (P interaction = 0.008). When compared with their normal-weight counterparts, obese African American girls (OR, 0.65; 95% CI, 0.41–1.05) were more likely to have better controlled asthma, whereas Mexican American girls had a 1.91 (95% CI, 1.12–3.28) greater odds of worse asthma control.
Conclusions: Worse asthma control is uniformly associated with increased body mass index in boys. Among girls, the direction of this association varied with race/ethnicity.
doi:10.1164/rccm.201211-2116OC
PMCID: PMC3678111  PMID: 23392439
obesity; asthma control; race and ethnicity; age; sex
12.  Prevalence of Psychiatric Illnesses among Ethnic Minority Elderly 
OBJECTIVES
To compare lifetime and 12-month prevalence of DSM-IV psychiatric disorders among a national representative sample of older Latinos, Asians, African-Americans, and Afro-Caribbean to non-Latino Whites.
DESIGN
Cross-sectional study conducted in 2001 through 2004.
SETTING
Urban and rural households in the contiguous United States.
PARTICIPANTS
A total of 4,245 community-dwelling residents aged 50 and older living in non-institutional settings. Data are from the NIMH Collaborative Psychiatric Epidemiology Surveys.
METHODS
The World Health Organization Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Interviewers matched the cultural background and language preference of participants. Bayesian estimates compared psychiatric disorder prevalence rates among ethnic/racial groups.
RESULTS
After gender adjustments, older non-Latino Whites had higher lifetime rates of any depressive disorder than African-Americans but were no different than older Latinos. Older Asians and Afro-Caribbean had significantly lower lifetime rates of any depressive, anxiety, and substance use disorders than non-Latino Whites. Immigrant Asians had higher lifetime rates of GAD than the U.S.-born Asians and immigrant Latinos had higher lifetime rates of dysthymia and GAD than U. S.-born Latinos. U.S. born Latinos had higher lifetime rates of substance abuse, especially alcohol abuse, than immigrant Latinos. There were no significant differences in the rates of 12-month psychiatric disorders between non-Latino whites and ethnic/racial minorities, except that older African-Americans had higher 12-month rates of any substance use disorder compared to non-Latino Whites.
CONCLUSION
Prevalence rates vary considerably by ethnicity and race as well as by nativity for older minorities, suggesting different patterns of illness and risk.
doi:10.1111/j.1532-5415.2009.02685.x
PMCID: PMC2854540  PMID: 20374401
ethnicity; prevalence; psychiatric illness; older adults
13.  The prevalence of asthma in children of elementary school age in Western New York 
To determine the prevalence of caregiver-reported asthma in children 4 to 13 years old in metropolitan western New York State, surveys were conducted during 1997–1999 in the Buffalo, Niagara Falls, Iroquois, and Gowanda school systems. Questionaires (3,889) were sent to the homes of elementary school children in nine schools in western New York. The caregivers were asked to complete a 13-item questionnaire for the child. Of the questionnaires, 60.5% (2,353/3,889) were completed.
Of all children, 18% had physician-diagnosed asthma. Of children diagnosed with asthma, 86% were taking medication. Symptoms were consistent with suspected undiagnosed asthma for 13% of the children. Buffalo had the highest rate of diagnosed asthma (20%) for the age group. Gowanda had a prevalence of 18%, Iroquois 16%, and Niagara Falls 15%. Variations were observed in asthma prevalence rates among different racial/ ethnic groups. In general, boys had a significantly (P=.001) increased odds of being asthmatic compared with girls. Overall, African-Americans and Hispanic/Latino children had significantly (P=.012 andP=.005, respectively) higher asthma prevalence rates, two to five times those of their Caucasian peers. In Gowanda, the prevalence of diagnosed asthma among Native American children was 23%, compared to 15% among Caucasian children. Of diagnosed Native American children, 71% were female. In Gowanda, a significant association (P=.007) of asthma among children in split-grade classes was observed compared to nonsplit grades. Of Native American children in split grades, 60% were diagnosed asthmatics. These observations reveal a high prevalence of asthma in the age group of 4 to 13 year olds in western New York. Local variations in potential triggers of asthma need to be considered when advising asthmatics. The results suggest that some grades have a disproportionate amount of children with asthma. The implications of asthma for children's early education need to be examined further.
doi:10.1007/BF02344035
PMCID: PMC3456761  PMID: 11194314
14.  Influence of Race and Socioeconomic Status on Engagement in Pediatric Primary Care 
Patient Education and Counseling  2011;87(3):319-326.
Objective
To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status.
Methods
Visit videos and parent surveys were obtained for 405 children who visited for respiratory infections. Family and physician engagement in key visit tasks (relationship building, information exchange, and decision making) were coded. Two parallel regression models adjusting for covariates and clustering by physician were constructed: 1) race/ethnicity only and 2) race/ethnicity with SES (education and income).
Results
With and without adjustment for SES, physicians seeing Asian families spoke 24% fewer relationship building utterances, compared to physicians seeing White, non-Latino families (p<0.05). Latino families gathered 24% less information than White, non-Latino families (p<0.05), but accounting for SES mitigates this association. Similarly, African American families were significantly less likely to be actively engaged in decision making (OR=0.32; p<0.05), compared to White, non-Latino families, but adjusting for SES mitigated this association.
Conclusion
While engagement during pediatric visits differed by the family’s race/ethnicity, many of these differences were eliminated by accounting for socioeconomic status.
Practice implications
Effective targeting and evaluation of interventions to reduce health disparities through improving engagement must extend beyond race/ethnicity to consider socioeconomic status more broadly.
doi:10.1016/j.pec.2011.09.012
PMCID: PMC3359403  PMID: 22070902
race/ethnicity; income; education; communication; engagement; Roter Interaction Analysis System (RIAS); decision making; upper respiratory infection; pediatrics; primary care; negative binomial regression
15.  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
16.  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
17.  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
18.  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
19.  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
20.  Increased healthcare resource utilization among Latino infants with acute respiratory illness compared with other racial/ethnic groups 
The Journal of pediatrics  2013;163(4):1186-1191.
OBJECTIVE
To examine healthcare resource utilization for Latino infants with acute respiratory illness compared with other racial/ethnic groups.
STUDY DESIGN
We studied 674 term, previously healthy infants presenting for an unscheduled healthcare visit for acute respiratory illness. The predictor variable was infant race/ethnicity, and the primary outcome was healthcare resource utilization, adjusted for age and disease severity.
RESULTS
The cohort was 14% Latino, 52% white, 22% African-American, and 12% other races/ethnicities. Mothers of Latino infants were 37% Spanish-speaking. Bronchiolitis severity score was higher (indicating more severe disease) in white infants (median 6.0, interquartile range 3.0–9.0, on a 0–12 point scale) versus Latinos (3.0, 1.0–6.0) and African-Americans (3.5, 1.0–6.0), p<0.001 for the comparison of all groups. Disease severity was similar between Latino and African-American infants (p=0.96). Latino infants were the group most likely to receive antibiotics (58% of Latinos, 47% of whites, 34% of African-Americans, p=0.005) and have body fluid cultures drawn. Latino infants were also more likely than African-Americans to have chest x-rays and respiratory virus rapid antigen testing (p≤0.01). Latino infants from Spanish-speaking families, compared with those from English-speaking families, had increased receipt of RSV testing (76% versus 51%, p=0.016).
CONCLUSIONS
Providers caring for Latino infants with acute respiratory illness ordered more antibiotics and diagnostic testing for this group, particularly compared with African-Americans, who have similar disease severity and socioeconomic disparities. This suggests that the language barrier may be a potential explanation for observed differences.
doi:10.1016/j.jpeds.2013.04.029
PMCID: PMC3935481  PMID: 23706603
bronchiolitis; healthcare utilization; Latino
21.  Ethnic Comparison of Attitudes and Beliefs About Cigarette Smoking 
OBJECTIVE
To determine if hypothesized differences in attitudes and beliefs about cigarette smoking between Latino and non-Latino white smokers are independent of years of formal education and number of cigarettes smoked per day.
DESIGN
Cross-sectional survey using a random digit dial telephone method.
SETTING
San Francisco census tracts with at least 10% Latinos in the 1990 Census.
PARTICIPANTS
Three hundred twelve Latinos (198 men and 114 women) and 354 non-Latino whites (186 men and 168 women), 18 to 65 years of age, who were current cigarette smokers participated.
MEASUREMENTS AND MAIN RESULTS
Self-reports of cigarette smoking behavior, antecedents to smoking, reasons to quit smoking, and reasons to continue smoking were the measures. Latino smokers were younger (36.6 vs 39.6 years, p < .01), had fewer years of education (11.0 vs 14.3 years, p < .001), and smoked on average fewer cigarettes per day (9.7 vs 20.1, p < .001). Compared with whites, Latino smokers were less likely to report smoking “almost always or often” after 13 of 17 antecedents (each p < .001), and more likely to consider it important to quit for 12 of 15 reasons (each p < .001). In multivariate analyses after adjusting for gender, age, education, income, and number of cigarettes smoked per day, Latino ethnicity was a significant predictor of being less likely to smoke while talking on the telephone (odds ratio [OR] 0.41; 95% confidence interval [CI] 0.26, 0.64), drinking alcoholic beverages (OR 0.66; 95% CI 0.44, 0.99), after eating (OR 0.55, 95% CI 0.37, 0.81), or at a bar (OR 0.62, 95% CI 0.41, 0.94), and a significant predictor of being more likely to smoke at a party (OR 1.72; 95% CI 1.14, 2.60). Latino ethnicity was a significant predictor of considering quitting important because of being criticized by family (OR 1.93; 95% CI 1.26, 2.98), burning clothes (OR 1.57; 95% CI 1.02, 2.42), damaging children's health (OR 1.67; 95% CI 1.08, 2.57), bad breath (OR 2.07; 95% CI 1.40, 3.06), family pressure (OR 1.67; 95% CI 1.10, 2.60), and being a good example to children (OR 1.83; 95% CI 1.21, 2.76).
CONCLUSIONS
Differences in attitudes and beliefs about cigarette smoking between Latinos and whites are independent of education and number of cigarettes smoked. We recommend that these ethnic differences be incorporated into smoking cessation interventions for Latino smokers.
doi:10.1046/j.1525-1497.1998.00051.x
PMCID: PMC1496925  PMID: 9541373
cigarette smoking; Latinos; Hispanics; culture
22.  House Poor in Los Angeles: Examining Patterns of Housing-Induced Poverty by Race, Nativity, and Legal Status* 
Housing policy debate  2012;22(4):605-631.
Housing affordability in the United States is generally operationalized using the ratio approach, with those allocating more than thirty percent of income to shelter costs considered to have housing affordability challenges. Alternative standards have been developed that focus on residual income, whether income remaining after housing expenditures is sufficient to meet non-housing needs.
This study employs Los Angeles Family and Neighborhood Survey data to consider racial/ethnic, nativity and legal status differences in one residual income standard. Logistic regression analyses of housing-induced poverty focus on whether there are differences among five distinct groups: U.S.born Latinos, Non-Hispanic Whites, and African Americans, authorized Latino immigrants, and unauthorized Latino immigrants. Results suggest that: 1) Latino natives are significantly more likely to be in housing-induced poverty than African Americans and Latino immigrants, and 2) unauthorized Latino immigrants are not more likely to experience the outcome than other groups.
The present work extends previous research. First, the results provide additional evidence of the value of operationalizing housing affordability using a residual income standard. Alternatives to the ratio approach deserve more empirical attention from a wider range of scholars and policymakers interested in housing affordability. Second, housing scholarship to date generally differentiates among Latinos by ethnicity, nativity, and citizenship. The present study contributes to emerging research investigating heterogeneity among Latinos by nativity and legal status.
doi:10.1080/10511482.2012.697908
PMCID: PMC3620202  PMID: 23585711
Affordability; Immigration; Minorities; Residual Income
23.  Recruiting Ethnically Diverse General Internal Medicine Patients for a Telephone Survey on Physician-Patient Communication 
BACKGROUND
Limited evidence exists on the effectiveness of recruitment methods among diverse populations.
OBKECTIVE
Describe response rates by recruitment stage, ethnic-language group, and type of initial contact letter (for African-American and Latino patients).
DESIGN
Tracking of response status by recruitment stage and ethnic-language group and a randomized trial of ethnically tailored initial letters nested within a cross-sectional telephone survey on physician-patient communication.
PARTICIPANTS
Adult general medicine patients with ≥1 visit during the preceding year, stratified by 4 categories: African-American (N= 1,400), English-speaking Latino (N= 894), Spanish-speaking Latino (N= 965), and non-Latino white (N= 1,400).
MEASUREMENTS AND RESULTS
Ethnically tailored initial letters referred to shortages of African-American (or Latino) physicians and the need to learn about the experiences of African-American (or Latino) patients communicating with physicians. Of 2,482 patients contacted, eligible, and able to participate (identified eligibles), 69.9% completed the survey. Thirty-nine percent of the sampling frame was unable to be contacted, with losses higher among non-Latino whites (46.5%) and African Americans (44.2%) than among English-speaking (32.3%) and Spanish-speaking Latinos (25.1%). For identified eligibles, response rates were highest among Spanish-speaking Latinos (75.2%), lowest for non-Latino whites (66.4%), and intermediate for African Americans (69.7%) and English-speaking Latinos (68.1%). There were no differences in overall response rates between patients receiving ethnically tailored letters (72.2%) and those receiving general letters (70.0%).
CONCLUSIONS
Household contact and individual response rates differed by ethnic-language group, highlighting the importance of tracking losses by stage and subpopulation. Careful attention to recruitment yielded acceptable response rates among all groups.
doi:10.1111/j.1525-1497.2005.0078.x
PMCID: PMC1490122  PMID: 15963168
recruitment; telephone survey; African Americans; Latinos; physician-patient communication
24.  Base excision repair genes and risk of lung cancer among San Francisco Bay Area Latinos and African-Americans 
Carcinogenesis  2008;30(1):78-87.
Base excision repair (BER) is the primary DNA damage repair mechanism for repairing small base lesions resulting from oxidation and alkylation damage. This study examines the association between 24 single-nucleotide polymorphisms (SNPs) belonging to five BER genes (XRCC1, APEX1, PARP1, MUTYH and OGG1) and lung cancer among Latinos (113 cases and 299 controls) and African-Americans (255 cases and 280 controls). The goal was to evaluate the differences in genetic contribution to lung cancer risk by ethnic groups. Analyses of individual SNPs and haplotypes were performed using unconditional logistic regressions adjusted for age, sex and genetic ancestry. Four SNPs among Latinos and one SNP among African-Americans were significantly (P < 0.05) associated with either risk of all lung cancer or non-small cell lung cancer (NSCLC). However, only the association between XRCC1 Arg399Gln (rs25487) and NSCLC among Latinos (odds ratio associated with every copy of Gln = 1.52; 95% confidence interval: 1.01–2.28) had a false-positive report probability of <0.5. Arg399Gln is a SNP with some functional evidence and has been shown previously to be an important SNP associated with lung cancer, mostly for Asians. Since the analyses were adjusted for genetic ancestry, the observed association between Arg399Gln and NSCLC among Latinos is unlikely to be confounded by population stratification; however, this result needs to be confirmed by additional studies among the Latino population. This study suggests that there are genetic differences in the association between BER pathway and lung cancer between Latinos and African-Americans.
doi:10.1093/carcin/bgn261
PMCID: PMC2722143  PMID: 19029194
25.  The Impact of Health Literacy and Socioeconomic Status on Asthma Disparities 
Objective
Racial/ethnic disparities have been well documented in asthma. While socioeconomic status (SES) has been repeatedly implicated as a root cause, the role of limited health literacy has not been extensively studied. The purpose of this study was to examine the independent contributions of SES and health literacy in explaining asthma disparities.
Methods
A cohort study was conducted in a Chicago-based sample of 353 adults aged 18–40 years with persistent asthma from 2004 to 2007. Health literacy, SES, and asthma outcomes including disease control, quality of life, emergency department visits, and hospitalizations were assessed in person at baseline, and asthma outcomes were measured every 3 months for 2 years by phone. Multivariate models were used to assess racial/ethnic disparities in asthma outcomes and the effect of health literacy and SES on these estimates.
Results
Compared with White participants, African American adults fared significantly worse in all asthma outcomes (p < .05) and Latino participants had lower quality of life (β = −0.47; 95% confidence interval [CI]= −0.79, −0.14; p = .01) and worse asthma control (risk ratio [RR] = 0.63; 95% CI = 0.41, 0.98; p = .04). Differences in SES partially explained these disparities. Health literacy explained an additional 20.2% of differences in quality of life between Latinos and Whites, but differences in hospitalization rates between African American and White adults remained (RR = 2.97; 95% CI = 1.09, 8.12, p = .03).
Conclusions
Health literacy appears to be an overlooked factor explaining racial and ethnic disparities in asthma. Evidence-based low literacy strategies for patient education and counseling should be included in comprehensive interventions.
doi:10.3109/02770903.2011.648297
PMCID: PMC3509174  PMID: 22277072
control; hospitalization; quality of life; race/ethnicity

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