Elevated Asthma Morbidity In Puerto Rican Children: Research Implications

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This paper has examined what is known about why children of Latino backgrounds have different prevalences of asthma. This review raises two questions. Why do Puerto Rican children have the highest prevalence of asthma among all Latino and non-Latino children in the United States? Why do Mexican American children, in spite of poverty and lack of access to care, appear to have a lower prevalence of asthma than Puerto Rican children?

Research Hypotheses
Our overarching hypothesis is that Puerto Rican children have higher prevalence of and morbidity from asthma because of an interaction of genetic predisposition and exposure to social and physical environmental risk factors.

Testing this hypothesis should involve a step-wise approach. First, bivariate analyses should test for main effects or major risk factors associated with an increased prevalence of asthma. Second, multivariate analyses should test for secondary or combined effects. A multivariate approach can control for confounding or bias, examine possible interaction effects, and “explain” ethnic differences in terms of specific risk and prognostic factors for asthma.
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We propose the following five hypotheses to evaluate differences in the prevalence and morbidity of asthma between Latino and non-Latino children and between subgroups of Latino children. First, we propose that children of Puerto Rican ancestry have a higher genetic or biologic predisposition to asthma. Research to date indicates that Puerto Rican children have a higher prevalence of asthma than Mexican American, Cuban American, and other non-Latino children. It is likely that these differences are attributable in part to differences in the immune predisposition to asthma among Latinos. Thus, the first main effect to test is ethnic ancestry or family country of origin, because ethnic differences may be attributed to unmeasured genetic or biological factors.

As a second hypothesis, we propose that the higher prevalence and morbidity of asthma in poor children is associated with multiple poverty-related risk factors. Asthma prevalence is higher among poor US children. Poverty is associated with such risk and prognostic factors for asthma as poor access to care, detrimental home exposures, and unstable family structures. Although research has shown the independent effects of these factors, we need to investigate whether these factors have a greater effect when they occur simultaneously. The lower prevalence of asthma in Cuban American children may be due to a positive association between protective risk factors and socioeconomic status, measured by parental education and income. On the other hand, Puerto Rican children have the highest morbidity from asthma and are also the poorest in the United States. Therefore, the effects of poverty and its related risk factors need to be researched. Canadian Pharmacy prednisone

Third, we propose that Puerto Rican, Mexican American, and Cuban American families have different family structures and related social risk factors. The association between poverty and higher incidences of asthma among Puerto Rican children and between a lack of poverty and lower incidences of asthma among Cuban American children does not hold for Mexican American children. One possible explanation is that Mexican American children have a lower frequency of social risk factors, such as single-parent households, relative to Puerto Rican children. In addition, migration may be associated with positive or negative risk factors. Immigrants may have higher socioeconomic status than residents of their country of origin and more resilient behaviors, such as seeking out the best possible access to health care for their children. For example, it is possible that Puerto Rican children born and raised on the island of Puerto Rico have a higher asthma morbidity than mainland Puerto Rican children born and raised in the continental United States. Yet, immigration may also be associated with negative risk factors, such as a lack of social or extended family support. Thus, the combined effects of family risk factors and ethnicity need to be studied.

Fourth, we propose that poor children of Puerto Rican ancestry have a higher prevalence of asthma than nonpoor Puerto Rican children. This hypothesis tests whether poverty and its associated risk factors compound the risk associated with country of origin and genetic ancestry. Because most Puerto Rican children with asthma are poor, the observed differences among ethnic groups are likely to result from the combined effect of these factors.
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Finally, we propose that Puerto Rican, Mexican American, and Cuban American families have different migration patterns and reside in US geographic sites associated with different physical and social environmental exposures. Latino children of different backgrounds are unevenly distributed across the United States. Most Puerto Rican children live on the island of Puerto Rico or in the Northeast and Illinois, with the largest mainland concentrations residing in New York City, Chicago, and Philadelphia. Most Mexican American children live in the Southwest, or in Los Angeles and Houston, although a significant number also live in Chicago. Most Cuban American children live in Miami. Thus, we need to study whether the main effect of Latino ethnicity or genetic ancestry may be partially explained by location and whether location may in turn be partially explained by environmental factors. For example, higher morbidity in mainland Puerto Rican children may be related to living in impoverished neighborhoods of New York City with high levels of outdoor pollution and crowded inner-city home environments conducive to asthma.

Research Strategies
We propose that future research should use available national epidemiological databases to test preliminary hypotheses as to the effects of some of the identified risk and prognostic factors. Research should also evaluate the relative contribution of all important risk factors through longitudinal observational studies, identify the mutability of some risk factors through intervention, and evaluate the cost-effectiveness of multi-component interventions. In addition, research would be enhanced by the use of measures shown to be reliable and valid in non-English-speaking populations of varied cultural backgrounds.
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The previously listed hypotheses cannot be tested using currently available information; however, population-based databases, such as the annual National Health Interview Survey, could be used to explore the role of some of the identified risk factors. These databases are representative of the US population and can be used to compare asthma prevalences between Latinos and non-Latinos, as well as among Latinos of the same country of origin living in different geographic locations in the United States. The risk factors accounted for by these databases are limited to self-identified ethnicity and to some indicators of access to care and socioeconomic status. Yet, the available population-based information can be used to estimate the relative importance of risk factors. In addition, using data from multiple years both increases sample size and facilitates the uncovering of time trends in asthma prevalence.

Longitudinal cohort studies are necessary for a more in-depth evaluation of the risk and prognostic factors associated with the incidence and remission of asthma. Prospective observational data can help determine whether risk factors are positive (causal) or negative (protective) with less potential bias than data from cross-sectional studies. The more detailed information obtained by such studies allows for the determination of patterns among the risk factors and for more extensive testing of combined and interaction effects. For example, rather than measuring ethnicity and geographic location solely by self-identified ethnicity, these effects can be measured in multiple ways, for instance by parent’s place of birth and residence, child’s place of birth, and child’s early life and current residences. Physiologic markers, such as genetic markers and pulmonary function, can be measured. More specific information regarding the accessibility and quality of care can be obtained. Yet, following procedures to assure that samples are representative and tracking subjects longitudinally can be very time-consuming and expensive. buy Omnicef 300

Intervention research can provide information regarding the mutability of risk and prognostic factors. Given that asthma is most likely a multifactorial illness, intervention research can help determine empirically which factors are most important in preventing asthma and reducing its morbidity. Intervention studies can be directed at single risk factors or “bundled” to reduce multiple risks simultaneously. Research to date suggests that single medical and educational interventions to treat asthma can reduce morbidity. Additional intervention research would provide information about the relative contribution of home environmental risk factors. At present, however, a multifactorial intervention that accounts for changes in health care, as well as for social and physical environmental factors, has yet to be conducted so that the independent and combined effects of these factors on asthma outcomes can be rigorously determined.

In particular, research is needed that develops and evaluates interventions to modify risk and prognostic factors among Latino children and their families. These interventions would aim to improve mental, physical, and functional health.