Caregivers of children with asthma smoke at a rate similar to the general population. Research on the relative importance of structural or functional social support in smoking cessation has been mixed. Participants were smokers (N=154) who were caregivers of children with asthma. Both functional (perception of social support measured by the Interpersonal Support Evaluation List) and structural social support (living with another smoker, partner status, and the proportion of smoking friends) were measured at baseline. Participants received an asthma-education and smoking cessation intervention based on Motivational Interviewing. Biochemically-verified abstinence was assessed at 6-months post treatment. Hierarchical logistic regression analyses indicated that functional support predicted smoking abstinence even when controlling for relevant covariates and structural support (OR = .896, p=.025). Exploratory analyses revealed that this effect was driven primarily by the self-esteem ISEL subscale. Structural support (lower proportion of smoking friends), but not functional support, predicted making a 24-hour quit attempt (OR = 1.476, p=.031) but this effect became non-significant when the effect of functional support was accounted for. Smoking cessation that focuses on building general functional support, particularly self-esteem support, may be beneficial for smoking cessation in caregivers of children with asthma.
Asthma; cigarette smoking; social support
Objectives To identify children demonstrating “good” sleep health in a sample of urban children with persistent asthma; to compare sociocontextual, asthma clinical characteristics, and sleep behaviors in children with “good” versus “poor” sleep health; and to examine protective effects of family-based health behaviors on sleep health. Methods Participants were 249 Black (33%), Latino (51%) and non-Latino White (16%) children with asthma, ages 7–9 years, and their primary caregivers. Results 32 percent of children had “good” sleep health. Well-controlled asthma and better lung function were more likely in this group. In the context of urban risks, sleep hygiene appeared to be a protective factor associated with better sleep quality. The protective effect of asthma management functioned differently by ethnic group. Conclusions This study identifies protective processes that may guard against urban risks to optimize sleep health in children with asthma. Intervention programs can be tailored to consider specific supports that enhance sleep health in this high-risk group.
asthma; children; disparities; health behavior; race/ethnicity; resilience; sleep
This special issue of the Journal of Pediatric Psychology showcases a growing area of research with a collection of 16 contemporary studies of resilience in youth with chronic medical or developmental conditions and their families. The research reported in this special issue covers a broad range of pediatric populations, including cancer, type 1 diabetes, and chronic pain, among others, ranging in age from early childhood through early adulthood. This introduction to the special issue reviews the various ways the articles' authors conceptualize and define risk and resilience; most analyze protective processes in relation to resilient outcomes, including both achievement of explicitly positive experiences and avoidance of dysfunction or disruption. Challenges with measurement of resilience-related constructs is reviewed. Finally, the special issue editors offer a definition of resilience in the context of pediatric and health psychology.
adjustment; chronic illness; resilience; risk
Objective To compare asthma care roles of maternal and paternal caregivers, and examine associations between caregiver involvement and the outcomes of adherence, morbidity, and parental quality of life (QoL). Methods Mothers and fathers in 63 families of children, ages 5–9 years, with persistent asthma completed semistructured interviews and questionnaires. Adherence was measured via electronic monitoring. Paired t tests compared parental asthma care roles, and analysis of covariance, controlling for socioeconomic status, evaluated associations of asthma outcomes with caregiver involvement scores. Results Mothers had higher scores on measures of involvement, beliefs in medication necessity, and on four subscales of the Family Asthma Management System Scale interview (Asthma Knowledge, Relationship with Provider, Symptom Assessment, and Response to Symptoms). Maternal QoL was lowest when both maternal and paternal involvement was high. Paternal involvement was associated with increased morbidity. Conclusions There is room for enhancement of fathers’ asthma care roles. Higher levels of paternal involvement may be driven by family need.
adherence; asthma; co-parenting; fathers; paternal; pediatric; quality of life
No studies have examined the differences in smoking attitudes and behavior between Dominicans (DRs) and Puerto Ricans (PRs). Identification of pretreatment differences is important for cultural adaptation of evidenced-based smoking cessation treatments.
Three home visits for asthma education and smoking cessation.
Caregivers who smoke and have a child with asthma: DRs (n = 30), PRs (n = 67), and non-Latino whites (n = 128; NLWs).
Baseline assessment of psychosocial variables.
Controlled for age, education, and acculturation.
Compared with DRs, PRs were more acculturated, more nicotine dependent, less motivated and confident to quit, and identified more pros of smoking (all p < .05). Compared with NLWs, PRs were less likely to be employed, smoked fewer cigarettes per day, and had lower education, greater depressed mood, greater pros and cons of smoking, less social support, and higher child asthma morbidity (all p < .05). Compared with NLWs, DRs were less nicotine dependent, more confident to quit, and less likely to live with a smoker; reported greater cons of smoking and greater stress; and were more likely to have a household smoking ban (DRs 60% vs. NLWs 33.6%). Only 3.3% of DRs were precontemplators vs. 16.4% (PRs) and 10.9% (NLWs).
PRs appear to have more factors associated with risk of smoking treatment failure; DRs appear to have more protective factors. Examination of the role of these smoking attitudes as potential moderators and mediators of smoking behavior are needed to guide the cultural adaptation of evidenced-based treatments.
Acculturation; Smoking Behavior; Latinos; Puerto Ricans; Dominicans; Hispanic Americans; Non-Latino Whites; Smoking Cessation; Medically Underserved; Prevention Research
Objective Develop a measure that evaluates effective pediatric food allergy (FA) management, child and parent FA anxiety, and integration of FA into family life. Methods A semistructured family interview was developed to evaluate FA management using a pilot sample (n = 27). Rating scales evaluated eight dimensions of FA management (FAMComposite), child anxiety, parent anxiety, and overall balanced integration (BI). Families of children with IgE-mediated food allergies (n = 60, child age: 6–12) were recruited for interview and rating scale validation. Results FAMComposite was correlated with physician ratings for families’ food avoidance and reaction response readiness. FA anxiety was correlated with general anxiety measures for children, but not parents. Parents’ FA anxiety was correlated with expectations of negative outcomes from FA. Low BI was associated with poor quality of life and negative impact on family functioning. Conclusions Preliminary analyses support Food Allergy Management and Adaptation Scale validity as a measure of family adaptation to pediatric FA.
family adaptation; management; pediatric food allergy; psychosocial adjustment
Rationale: Stress is associated with asthma morbidity in Puerto Ricans (PRs), who have reduced bronchodilator response (BDR).
Objectives: To examine whether stress and/or a gene regulating anxiety (ADCYAP1R1) is associated with BDR in PR and non-PR children with asthma.
Methods: This was a cross-sectional study of stress and BDR (percent change in FEV1 after BD) in 234 PRs ages 9–14 years with asthma. We assessed child stress using the Checklist of Children’s Distress Symptoms, and maternal stress using the Perceived Stress Scale. Replication analyses were conducted in two cohorts. Polymorphisms in ADCYAP1R1 were genotyped in our study and six replication studies. Multivariable models of stress and BDR were adjusted for age, sex, income, environmental tobacco smoke, and use of inhaled corticosteroids.
Measurements and Main Results: High child stress was associated with reduced BDR in three cohorts. PR children who were highly stressed (upper quartile, Checklist of Children’s Distress Symptoms) and whose mothers had high stress (upper quartile, Perceived Stress Scale) had a BDR that was 10.2% (95% confidence interval, 6.1–14.2%) lower than children who had neither high stress nor a highly stressed mother. A polymorphism in ADCYAP1R1 (rs34548976) was associated with reduced BDR. This single-nucleotide polymorphism is associated with reduced expression of the gene for the β2-adrenergic receptor (ADRB2) in CD4+ lymphocytes of subjects with asthma, and it affects brain connectivity of the amygdala and the insula (a biomarker of anxiety).
Conclusions: High child stress and an ADCYAP1R1 single-nucleotide polymorphism are associated with reduced BDR in children with asthma. This is likely caused by down-regulation of ADRB2 in highly stressed children.
asthma; Puerto Ricans; bronchodilator response; stress
The current study sought to evaluate patterns of complementary and alternative medicine (CAM) use in a sample of Latino and Non-Latino white (NLW) children with asthma, to determine whether parental beliefs about conventional medications and barriers to obtaining these medications were related to CAM use, and to assess whether CAM use was associated with decreased adherence to controller medications.
Participants included 574 families of children with asthma from Non-Latino White, Puerto Rican, and Dominican backgrounds from RI and from Island Puerto Rico. All parents completed a brief checklist of barriers to medication use and an assessment of CAM approaches. A subsample of 259 families had controller medication use monitored objectively for approximately one month by MDILog (fluticasone propionate), TrackCap (montelukast), or dosage counter (fluticasone/salmeterol combination).
Prevalence of CAM use was high among Latino families. Perceived barriers to obtaining medication were related to increased CAM use in Puerto Rican families from RI. Elevated medication concerns were positively associated with CAM use among NLW and Island PR families. CAM use was positively related to objective adherence within NLW families, and unrelated in other groups.
CAM use is common among Latino families with asthma. Among some families, CAM use may be initiated as a way to cope with barriers to obtaining medication or when parents have concerns about conventional medications. Families who report CAM use do not appear to be substituting CAM for conventional asthma medication.
Asthma; Adherence; Complementary and Alternative Medicine
Objective As a field, pediatric psychology has focused considerable efforts on the education and training of students and practitioners. Alongside a broader movement toward competency attainment in professional psychology and within the health professions, the Society of Pediatric Psychology commissioned a Task Force to establish core competencies in pediatric psychology and address the need for contemporary training recommendations. Methods The Task Force adapted the framework proposed by the Competency Benchmarks Work Group on preparing psychologists for health service practice and defined competencies applicable across training levels ranging from initial practicum training to entry into the professional workforce in pediatric psychology. Results Competencies within 6 cluster areas, including science, professionalism, interpersonal, application, education, and systems, and 1 crosscutting cluster, crosscutting knowledge competencies in pediatric psychology, are presented in this report. Conclusions Recommendations for the use of, and the further refinement of, these suggested competencies are discussed.
education; pediatric psychology; professional issues; training
Objective The current study examined the role of alternate caregivers (i.e., caregivers living outside of the home who spend at least 6 hr per week caring for the child) in a sample of Latino and non-Latino White (NLW) families with a child with asthma. Methods Participants included 665 families of children with asthma from NLW, Puerto Rican, and Dominican backgrounds from Rhode Island and Puerto Rico. All caregivers completed a validated semistructured family interview assessing asthma management strategies in the family context. Results 22 percent of families identified an alternate caregiver. Alternate caregiver involvement was highest among Island Puerto Rican families. Island Puerto Rican families who reported alternate caregiver involvement were rated as having higher medication adherence and more balanced adaptation to the demands of asthma management. Conclusions Alternate caregivers may play an important role in family asthma management, especially among some Latino subgroups.
asthma; culture; family functioning
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.
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.
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).
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.
asthma; patient nonadherence; disparities
Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a “capstone experience”; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the “business of science.” Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists.
empirically supported treatments; internship; training
Secondhand smoke (SHS) exposure remains a public health problem. Few, if any, studies include both children with and without asthma to assess differences in caregiver smoking behavior, risk perception, and SHS.
Participants were 738 daily U.S. smokers (443 caregivers of children with asthma [CG-AC] and 295 caregivers of healthy children [CG-HC]; 50.9% White, 25% Black, 15% Latino). Data are cross-sectional; SHS was measured through self-report and passive dosimetry.
Compared with CG-HC, CG-AC had fewer risk factors for exposing children to SHS (lower nicotine dependence, higher motivation to quit, greater perceived benefits of cessation on child’s health, and lower optimistic bias; all p values < .05). Specifically, 60.6% of CG-AC reported a household smoking ban versus 40.1% of CG-HC (p < .05), though >95% of both groups had detectable levels of SHS in their home. CG-AC self-reported lower SHS than CG-HC, but both groups had nearly equivalent SHS when measured objectively. CG-AC were almost twice as likely as CG-HC to report a home smoking ban when they had detectable levels of household SHS as measured by passive dosimetry (OR = 1.71; 95% CI = 1.2, 2.4; p = .003).
Caregivers of children with chronic health conditions, such as asthma, may be motivated to self-report lower levels of SHS. Child health status (e.g., asthma) may cue practitioners to inquire about SHS, but given the low proportion of household bans and high levels of actual exposure among both groups, SHS exposure assessment and reduction/elimination counseling should be prompted to occur for all children.
Previous investigations have produced mixed findings on whether youth with Inflammatory Bowel Disease (IBD) experience elevated rates of depressive symptoms. Our first aim was to compare self-report of depressive symptoms by youth with IBD to a community sample. The second aim was to examine the relationship between symptoms of depression and measures of disease activity.
Item-level responses on the Children's Depression Inventory (CDI) among a sample of 78 youth diagnosed with IBD were compared to responses from a community sample using one-sample t-tests. Particular attention was given to items assessing somatic symptoms of depression given the potential overlap with IBD disease symptoms. The relationship between depressive symptoms and IBD disease activity was evaluated using Spearman's rank correlation coefficients and linear regression.
Youth with IBD reported lower levels of depressive symptoms compared to the community sample on the CDI Total Score, and similar or lower levels of difficulty on items assessing somatic symptoms. The majority of the sample had inactive or mild disease activity at the time of participation, with 14% experiencing moderate/severe disease activity. Higher ratings of disease activity were related to greater depressive symptoms. Responses on somatic items from the CDI were not differentially related to disease activity.
As a group, pediatric patients with IBD did not experience clinical levels of depressive symptoms or elevations in depressive symptoms when compared to a community sample. Somatic symptoms of depression do not differentiate youth with IBD experiencing elevations in disease activity from youth experiencing non-somatic symptoms of depression.
Pediatric Inflammatory Bowel Disease; depression; disease activity
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
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.
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.
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).
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.
disparities; adherence; asthma; ethnicity; childhood; medication use
This study examines factors associated with recruitment and retention of Latino, Dominican (DR) and mainland Puerto Rican (PR), and non-Latino white (NLW) families into a pediatric asthma study. Over eleven hundred (n=1185) families were screened, and 489 (n= 174 NLW, n= 160 DR, n= 155 PR) were enrolled. Rates of recruitment by source of recruitment and rates of retention differed by ethnic group. Families whose caregiver had never married had lower odds of completing the study. The findings highlight the need for further study to examine the effectiveness of specific recruitment and retention strategies with Latino and non-Latino white families.
Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared to non-Latino whites. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed in order to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex and inter-related sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Clinical Implications: Several strategies that could be applied in clinical settings to reduce asthma disparities are described including the need for routine assessment of the patient’s beliefs, financial barriers to disease management, and health literacy, and the provision of cultural competence training and communication skills to health care provider groups.
Asthma disparities; multi-level model of asthma disparities; clinical recommendations
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.
Allergic rhinitis (AR) is a risk factor for the development of asthma, and if poorly controlled, it may exacerbate asthma. We sought to describe AR symptoms and treatment in a larger study about asthma, sleep, and school performance. We examined the proportion (1) who met criteria for AR in an urban sample of school children with persistent asthma symptoms, (2) whose caregivers stated that they were not told of their child's allergies, (3) who had AR but were not treated or were undertreated for the disease, as well as (4) caregivers and healthcare providers' perceptions of the child's allergy status compared with study assessment, and (5) associations between self-report of asthma and AR control over a 4-week monitoring period. One hundred sixty-six children with persistent asthma participated in a clinical evaluation of asthma and rhinitis, including allergy testing. Self-report of asthma control and rhinitis control using the Childhood Asthma Control Test (C-ACT) and Rhinitis Control Assessment Test (RCAT) were measured 1 month after the study clinic session. Persistent rhinitis symptoms were reported by 72% of participants; 54% of rhinitis symptoms were moderate in severity, though only 33% of the sample received adequate treatment. AR was newly diagnosed for 53% during the clinic evaluation. Only 15% reported using intranasal steroids. Participants with poorly controlled AR had poorer asthma control compared with those with well-controlled AR. This sample of urban school-aged children with persistent asthma had underdiagnosed and undertreated AR. Healthcare providers and caregivers in urban settings need additional education about the role of allergies in asthma, recognition of AR symptoms, and AR's essential function in the comanagement of asthma. Barriers to linkages with allergy specialists need to be identified.
Caregivers who smoke and have children with asthma are an important group for intervention. Home-based interventions successfully reduce asthma morbidity, yet are costly. This study evaluated the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program, a combined asthma education and smoking cessation intervention.
Participants included caregivers (n = 224) that smoked, had a child with asthma, and were enrolled in a Medicaid managed care plan. Participants received nurse-delivered asthma education and smoking counseling in three home visits. Program implementation costs were estimated, and health care expenses were obtained from insurance claims data 12 months pre- and 12 months post intervention. ROI was calculated for all participants, children < 6 years, children 6–18 years, and children with moderate/severe persistent asthma.
Total program implementation cost was $34,481. After intervention, there was increased mean annual refills of beta-agonist (0.51 pre, 1.64 post; p<0.001), and controller medications (0.65 pre, 2.44 post; p<0.001). Reductions were found in mean annual emergency department visits (0.33 pre, 0.14 post; p<0.001), hospitalizations (0.23 pre, 0.08 post; p<0.001), and outpatient visits (2.33 pre, 1.45 post, p<0.001). The program had negative ROI (−21.8%) for the entire sample. The ROI was positive (+106.9) for children < six years, negative (−150.3) for children 6–18, and negligible for moderate/severe persistent asthma (+6.9%).
PAQS was associated with increased medication use and decreased health care utilization. While the overall ROI for PAQS was negative, PAQS had a positive ROI for caregivers of young children with asthma.
Asthma; Pediatrics; Smoking Cessation; Education
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.
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.
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.
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.
pediatric asthma; quality of life; caregivers; disparities; ethnicity
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.
asthma outcomes; cultural factors; inner city; pediatric asthma; protective factors