Elevated Asthma Morbidity In Puerto Rican Children: Differences in Risk and Prognostic Factors

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Table 2 presents a conceptual summary of the possible risk and prognostic factors for asthma prevalence and morbidity that we have identified through a review of the scientific literature and clinical experience. For the purposes of this discussion, we distinguish between risk and prognostic factors. Causal risk factors are positively associated with incidence of disease, protective risk factors are negatively associated with incidence of disease, and prognostic factors affect the disease’s morbidity and remission, once it has occurred. Research to date, however, has not completely clarified whether certain factors are risk factors, prognostic factors, or both.

TABLE 2. – Possible Childhood Asthma Risk and Prognostic Factors.

Type	Cenetic/Bioiogk	Physical Environment	Social Environment
Mutable (amenable to intervention)	Low birth weight	Home exposures Early life Current Some outdoor exposures	Health care Screening Treatment Family & Community Support mechanisms Behaviors & beliefs
Immutable (very difficult to modify)	Ethnic ancestry Race Immune predisposition	Past home exposures Some outdoor exposures	Socioeconomic conditions Family psychosocial stressors

Before discussing risk and prognostic factors, it is important to keep in mind which are mutable, or given the current state of scientific knowledge, potentially modifiable through interventions. Immutable factors are very difficult, if not impossible, to modify. Classifying a factor as mutable or immutable in this scheme depends on the perspective of the intervention. From a traditional medical perspective, for instance, one would consider as immutable any factor over which the health care and public health care systems have no control. Examples include outdoor pollution and socioeconomic stressors, such as poverty and inappropriate housing. generic Imitrex online

Genetic Predisposition and Other Biologic Factors
Researchers currently regard asthma, the presence of recurrent but reversible respiratory obstruction symptoms, such as cough and wheezing, as a chronic inflammatory disorder of the airways that can have a strong allergic and hereditary component. canadian pharmacy Skelaxin

Preliminary research suggests that genetically determined differences in inflammatory response, particularly those related to the substance alpha-antitrypsin, may exist in Puerto Rican children with asthma. Genetic studies have shown that people with asthma can have an abnormal variant of alpha-antitrypsin (AAT), a protein related to inflammatory reactions and, more specifically, they can have elevated levels of the S or Z variant. Studies in the Bronx have shown that the increased incidence of asthma among mainland Puerto Rican adults and children is associated with AAT variant pheno-types. Although abnormal variants of AAT are unlikely to be solely responsible for the higher prevalence of asthma among Puerto Rican children, genetic differences may account in part for this difference.

Differences in the predisposition of Latino children to asthma may also be associated with two other physiologic factors can either be determined or exist at birth. These factors include differences in airway size and premature birth or low birth weight. One hypothesis for future study is that differences in asthma outcomes among Cuban American, Mexican American, and Puerto Rican children may be related to differences in airway size. Hsu and Dodge found that Mexican American children had better lung function than a comparison group of white or non-Mexican American children and speculated that the lower prevalence of asthma among Mexican Americans could be associated with larger airways that are less likely to wheeze.
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Oliveti has shown an association between asthma prevalence and prematurity and low birth weight among inner-city African American children. This association has yet to be studied with regard to Latino children. The differences in birth weight distribution among Latinos, however, are well described, with Mexican American and Cuban American children having higher birth weights than Puerto Rican children. These differences suggest that prematurity and low birth weight may also be risk factors for asthma among specific subsets of Latino children.

Differences in the Physical and Social Environment
In addition to genetic and physiologic factors, environmental and social factors have been implicated in both the development of asthma and the exacerbation of its symptoms. Research indicates that, among mostly non-Latino populations, the physical and social environment can affect both the development and expression of the disease. The effects of the physical environment include indoor or home exposures to such allergens as molds or pets and outdoor exposures to allergens like air pollution or pollens. The social environment’s influence involves the behaviors, beliefs, and structure of the immediate family unit, as well as those of the community and social culture in which the family operates.

Indoor and Outdoor Exposures
Exposures early in life to indoor allergens, such as cockroaches, can be associated with both the development of asthma and a greater occurrence of asthma symptoms. Preliminary data from NCICAS indicate that, compared with African American children, Latino children have a greater proportion of positive skin tests, which indicate abnormal allergic and inflammatory responses to indoor allergens. In a sample of mostly Mexican American children hospitalized for asthma in Los Angeles, Richards found that few families were instituting measures to avoid allergens in the home. Control of indoor or home asthma-aggravating environmental triggers is critical to the appropriate management of the illness.
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Research has yielded conflicting scientific evidence of the connection between asthma and air pollution. Some studies have described an association between daily air pollution levels and asthma symptoms, emergency room visits, and hospitalizations. Orengo, however, did not find a relationship between outdoor environmental pollutants and asthma prevalence on the island of Puerto Rico. The interpretation of some of these studies is difficult because of their ecological nature; they do not directly compare exposures. Possible differences, however, in the acute effects on symptoms and the chronic effects of air pollution have been described.

Differences in Family Structure and Community
The results of several studies suggest that differences in family behaviors, beliefs, structure, and function are associated with asthma morbidity. Parental smoking is a key behavior associated with asthma. Several studies in non-Latino populations have shown that children exposed to smoking are more likely to develop asthma. Differences in smoking behaviors among Latinas may be associated with different asthma outcomes for their children. The Hispanic Health and Nutrition Examination Survey showed that Puerto Rican women have the highest rate of smoking. Of Puerto Rican women between 12 and 49 years old, 32% smoke, compared to 23% of Cuban American and 21% of Mexican American women. Puerto Rican teenage girls have the highest prevalence of smoking: 16% of Puerto Rican teenage girls reported that they smoke, compared to 9% of Mexican American and 6% of Cuban American teenagers. Thus, a hypothesis for future research is that the higher prevalence of asthma among Puerto Rican children is associated with a higher prevalence of maternal smoking, particularly among teenage mothers. The effects of passive smoking and the indirect effect of smoking during pregnancy on intrauterine development may both influence the child’s asthma risk.
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Family beliefs regarding asthma and the efficacy of medical treatment can influence such health behaviors as seeking care and compliance with prescribed regimens. Scrimshaw reported an ethnographic study of Mexican Americans who viewed asthma as a disease for which conventional medical regimens are effective, but who considered ethnomedical rituals more effective in the treatment of seizures. Mainland Puerto Rican families sometimes treat asthma with folk or home remedies, which include rubbing the chest with oils and Vicks preparations, but almost all of them use medications or seek traditional medical care when a child has an asthma attack. When explaining differences in asthma prevalence and morbidity, it is important to consider ethnic-specific cultural beliefs and perceptions of illness, but not to the exclusion of universal health beliefs and behaviors that may be more central to the health issues and problems families encounter.

Research conducted among mostly non-Latino populations suggests that differences in family structure and function can affect the exacerbation of asthma symptoms, adherence to medical regimens, hospitalization, and mortality in children with asthma. In addition, some evidence suggests that exposure to a stressful family environment early in life can be associated with the development of asthma among genetically predisposed individuals. Documented differences in family and community structure among Latinos may be associated with better asthma outcomes in Mexican Americans. Protective social factors may include the higher prevalence of two-parent households among Mexican Americans and Cuban Americans, as compared to the higher rate of single motherhood among mainland Puerto Ricans.The concept of “familismo,” the presence and importance of extended family support structures among Mexican Americans, and the emphasis placed on higher education by Cuban Americans, could also be associated with an enhanced capacity to cope with the multiple demands of having a child with a chronic disease.

Another important aspect of the social environment that research on children with asthma has not emphasized is the evaluation and management of psychiatric comorbidities. Two national studies have documented the high prevalence (about 35%) of behavioral problems in children with asthma. A high prevalence of depression exists among mothers of inner-city children, particularly among mothers of children with asthma. Emerging research indicates that undiagnosed and untreated depression is a major health issue for Latinas (K. Wells, MD, MPH, oral communication, September 1998).

Access to Health and Public Health Care Services
Because appropriate medical care can control asthma symptoms, the quality of health care services and access to them are important determinants of outcome. Indicators of access to care include the presence of barriers to care, such as the lack of insurance, and the use of asthma services when the child needs them. The quality of asthma care depends on structural and process requirements for good asthma care, such as ensuring specialty training for the health care provider, maintaining an inventory of necessary equipment and medications, and providing the family with adequate asthma education and instruction for care. In addition, adequate coordination with community-based organizations, such as schools, is crucial when working with children and families to reduce asthma morbidity. The community and the various parts of the health care and public health care systems need to work together to help families resolve asthma-related issues. canadian pharmacy Levaquin

Accessing health care is a major problem for Latino children and their families; Latino families have a lower rate of health insurance than other minority groups and experience additional language and cultural barriers to health care. Finkelstein found that Latino preschoolers hospitalized for asthma were less likely man white children to receive maximal preventive therapy prior to hospital admission or to obtain equipment to help manage asthma after discharge. Preliminary results of NCICAS indicate that inner-city children with asthma experience significant barriers to care. Although about 95% of inner-city children with asthma reported having a regular place for attack or follow-up care, nearly half had difficulty obtaining follow-up care, about 25% experienced a long wait for an appointment, and 20% could not see their own doctor. More research is necessary to evaluate the accessibility and quality of care for children with asthma, as well as the relation of both to the level of morbidity among different groups of Latino children.