Abstract
Background:
Disparities in asthma morbidity between Black and non-Hispanic White children are well-documented, but less is known about differences between Mexican American and non-Hispanic White children.
Objective:
To examine differences in asthma control and treatment between Mexican American and non-Hispanic White children with persistent asthma in Central Texas. We also contextualized these differences relative to those observed between Black and non-Hispanic White children.
Methods:
Data were drawn from the Texas Home Assessment of Asthma and Lung Exposures study. Parents were surveyed about well-controlled asthma (defined as Asthma Control Test score ≥ 20), controller medication use in past two weeks, socioeconomic status, and healthcare access. Logistic regression models were used to evaluate associations between race and ethnicity and asthma outcomes, with and without adjustment for socioeconomic and healthcare access factors.
Results:
Among 202 children (46% Mexican American, 26% Black, 28% non-Hispanic White), Mexican American children had 81% lower odds of well-controlled asthma and 58% lower odds of controller medication use compared to non-Hispanic White children. These disparities persisted after adjusting for socioeconomic and healthcare access factors, though some associations were no longer statistically significant. Comparisons between Black and non-Hispanic White children demonstrated more pronounced disparities in asthma control and similar disparities in controller medication use.
Conclusion:
Mexican American and Black children were less likely to have controlled asthma and use controller medications, reflecting persistent disparities not fully explained by socioeconomic and healthcare access factors.
Keywords: Asthma Disparities, Mexican American Children, Pediatric Asthma, Asthma Control, Controller Medication Use, Socioeconomic Factors, Healthcare Access, Racial and Ethnic Disparities, Asthma Treatment, Healthcare Inequities
Capsule summary
This study highlights significant disparities in asthma control and treatment between Mexican American and non-Hispanic White children and demonstrates that traditional socioeconomic and healthcare access factors only partially explain these disparities.
INTRODUCTION
Asthma disparities between Black and Non-Hispanic White children in the United States are well-documented; however, disparities between Mexican American and Non-Hispanic White children remain underexplored. Historically, Latinx/Hispanic populations of greatest concern were those with the highest prevalence of asthma, such as Puerto Rican and Dominican American children(1, 2). However, recent data indicate that in spite of having a relatively lower prevalence of asthma compared to Non-Hispanic White children, Mexican American children are the only ethnic group experiencing an increase in asthma prevalence(3). Over the past several decades, the Mexican American population has grown significantly, both in absolute numbers and as a proportion of the overall U.S. population(4). This demographic shift, coupled with rising asthma prevalence, suggests that an increasing number of Mexican American children will be affected by asthma in the United States. Despite these trends, there is limited research on asthma morbidity in this population(5, 6).
National data indicate that Mexican American children with asthma have higher hospitalization and emergency department visit rates than Non-Hispanic White children with asthma(3). Similarly, recent studies from central Texas, where the majority of Latinx/Hispanic individuals are of Mexican origin, have highlighted an excess burden of asthma-related emergency department visits among Latinx/Hispanic children compared to Non-Hispanic White children(7, 8). In general, poor asthma control and underuse of long-term controller medications are well-established contributors to higher rates of emergency department utilization for asthma(9–11). Whether the observed excess emergency department visits and hospitalizations among Mexican American children relative to Non-Hispanic White children are associated with similar disparities in asthma control is unclear, as data on disparities in asthma control between Mexican American and Non-Hispanic White children are limited(12). Evidence of differences in long-term controller medication use, on the other hand, is available but is conflicting. One nationally representative study reported no differences in controller medication use(13), while another suggested that Mexican American children were less likely to use controller medications compared to Non-Hispanic White children(14).
To address existing gaps in the literature and better interpret emerging data on disparities in asthma morbidity between Mexican American and Non-Hispanic White children, we examined asthma control, asthma treatment, lung function, eosinophilic inflammation, and exacerbations among Mexican American, Black, and Non-Hispanic White children with persistent asthma in Central Texas. Given the evidence that Black and Mexican American children in the US have a higher prevalence of poverty and less access to health care(15–17), we also evaluated the extent to which any racial and ethnic disparities in asthma morbidity persisted after accounting for key socioeconomic and healthcare access factors.
METHODS
Study Population
We conducted a retrospective analysis using cross-sectional data from children enrolled in the Texas Home Assessment of Asthma and Lung Exposures (TexHALE) study. Between December 11, 2020, and May 20, 2024, children with persistent asthma were recruited from the Dell Children’s Medical Center Emergency Department, Dell Children’s Medical Group Allergy/Immunology Clinic, Dell Children’s Pediatric Pulmonary Clinics, and Community Care Health Centers, which collectively serve children from a range of socioeconomic, racial, and ethnic backgrounds. Eligible participants were children aged 5–17 years with persistent asthma, defined as meeting at least one of the following criteria: use of an inhaled corticosteroid (ICS) in the past two weeks, asthma symptoms on at least three days per week, or at least one nocturnal awakening due to asthma symptoms in the past two weeks. The study was approved by the Institutional Review Board at the University of Texas at Austin. Informed consent was obtained from all parents or legal guardians, and assent was obtained from children as appropriate.
Data Collection
Data were collected from children and their families through in-person surveys, spirometry, and measurements of fractional exhaled nitric oxide (FeNO) and serum immunoglobulin E (IgE). Surveys captured demographics, socioeconomic factors, asthma control, asthma treatment, asthma exacerbations, and healthcare access. Survey data for 19 participants enrolled during the height of the COVID-19 pandemic were collected remotely; spirometry and FeNO were not measured in these participants.
Demographic data included the child’s age, sex, and preferred language when visiting a doctor. Socioeconomic factors (household income and parental educational attainment) were assessed through parent survey responses. Households were classified as either (1) above the federal poverty level (FPL) or (2) below FPL using approximations that aligned income categories in the dataset with federal thresholds by household size(18). Household size was calculated as the sum of adults and children in the home. Parent/caregiver educational attainment was categorized as: (1) less than high school; (2) high school or some college; and (3) college graduate.
Healthcare access variables included the type of doctor primarily responsible for managing the child’s asthma (general doctor or specialist) and the child’s main source of health insurance. Insurance options were private insurance (e.g., Blue Cross/Blue Shield, employer-sponsored plans, or self-purchased plans) and public insurance (e.g., Medicaid or the Children’s Health Insurance Program). Parents also responded to a question about whether asthma care for the child had been delayed in the past 12 months due to a lack of transportation.
Asthma control was assessed using the Asthma Control Test (ACT), a validated 5-item questionnaire that evaluates shortness of breath, nighttime symptoms, reliever medication use (e.g., short-acting beta agonist), activity limitations, and self-rated control over the past 4 weeks(19). The ACT score was calculated and categorized into well-controlled asthma (ACT ≥ 20) and not well-controlled asthma (ACT < 20) (20, 21). Secondary measures of asthma control were reliever medication use at least once in the past two weeks and oral corticosteroid (e.g., dexamethasone, prednisone) use at least once in the past three months.
Asthma treatment was assessed from participants’ reports of prescription or use of controller medications (e.g., ICS, long-acting beta-agonist) in the past three months, use in the past two weeks, and frequency of use in the past two weeks. Participants were asked to show their medications to the study team to inform responses.
Lung function tests were performed using the VitalFlo spirometer (prior to August 16, 2022) and the EasyOne spirometer (after August 16, 2022) to measure FEV1, FVC, and FEV1/FVC. VitalFlo, used for 32.2% of participants, allowed for remote, app-based data collection during the COVID-19 pandemic, when in-home visits were not conducted. To assess the impact of the device change, we compared percent predicted (pp) FEV1 and FVC, and FEV1/FVC between devices using t-tests and found no statistically significant differences in mean values, supporting the consistency of lung function measurement across devices. Spirometry measures were reviewed by a trained respiratory therapist and graded (A-D) based on acceptability and repeatability. Only tests graded A or B were included in subsequent analyses. Percent predicted values were calculated based on the Global Lung Initiative’s race and ethnicity-neutral spirometry reference equations(22). FeNO, a marker of eosinophilic inflammation, was measured according to ERS/ATS guidelines(23) and using the NIOX Vero (Aerocrine AB, Solna, Sweden). Participants were asked to complete two exhalations; the mean of the two values, expressed as parts per billion (ppb), was used as our FeNO measurement unless only one measure was collected, in which case a single value was used. Atopy was defined as sensitization to at least one of six common allergens: cat, dog, dust mite (Dermatophagoides pteronyssinus), American cockroach, German cockroach, and mountain cedar(24, 25). Blood samples were collected, and serum was analyzed at Clinical Pathology Labs using the ImmunoCAP system (ThermoFisher, Uppsala, Sweden) to quantify allergen-specific IgE levels. Children were classified as sensitized to an allergen if their serum IgE concentration was ≥0.35 kU/L. To reflect the degree of atopy, a continuous variable was derived based on the number of allergens to which each child was sensitized.
Consistent with definitions of asthma exacerbations put forth by the Global Initiative for Asthma(26) and the National Asthma Education and Prevention Program Expert Panel Report 3(27), asthma exacerbations were captured by parent reports of asthma-related urgent care visits (hospitalization, emergency department visits, or unscheduled doctor visits) in the past 12 months.
Data Analysis
Data analyzed in this study were restricted to children whose parents or caregivers identified them as Mexican American, Black, or Non-Hispanic White. As a result, 39 children (15.5%) of non-Mexican American Hispanic origin, eight children (3.2%) identified as Asian, American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, or other race and ethnicity, and three children (1.2%) who refused to answer were excluded, resulting in a final sample of 202 children (80.2%). We examined racial and ethnic differences in demographics, socioeconomic factors, health care access, asthma control, treatment, lung function, FeNO, and asthma exacerbations. Additionally, we compared children with and without well-controlled asthma, as well as children who used controller medication in the past two weeks, to those who did not. Comparisons between groups were evaluated using t-tests, chi-squared tests, or Fisher’s exact tests, as appropriate. To directly address whether differences in asthma control and treatment could be explained by poverty or healthcare access, we ran logistic regression models in four steps: (1) adjusting for age and sex, (2) adjusting for age, sex, and socioeconomic factors (household income relative to the federal poverty level, parental education), (3) adjusting for age, sex, and healthcare access factors (insurance type, asthma care provider type, transportation barriers), and (4) adjusting for age, sex, socioeconomic, and healthcare access factors. Model (4) is cumulative, including all covariates from models (1)–(3). This allowed us to assess whether any observed differences by race and ethnicity persisted after accounting for socioeconomic and health care access factors. Analyses were conducted using R (version 4.4).
RESULTS
Study Population Characteristics
The sample included 202 children with asthma; 46.0% were Mexican American, 26.2% were Black, and 27.7% were Non-Hispanic White (Table I). The mean age was 10.5 years (± 3.4), and two-thirds were male. All Black and Non-Hispanic White families preferred speaking in English during medical visits, whereas 44% of Mexican American families preferred Spanish.
TABLE I.
Sociodemographic Characteristics, Asthma Control, and Treatment of Non-Hispanic White, Black and Mexican American Children in TexHALE. Data represent the mean ± SD, median [IQR], or the number of participants (%).
| Total (N=202) | Mexican American (N=93) | Black (N=53) | Non-Hispanic White (N=56) | Mexican American vs Non-Hispanic White p-value | Black vs Non-Hispanic White p-value | |
|---|---|---|---|---|---|---|
| Sociodemographic Characteristics | ||||||
| Age (years) | 10.5 ± 3.40 | 10.6 ± 3.27 | 11.2 ± 3.64 | 9.7 ± 3.25 | 0.10 | 0.03 |
| Male | 134 (66.3%) | 66 (71.0%) | 32 (60.4%) | 36 (64.3%) | 0.40 | 0.67 |
| Preferred Language English (N=198) | 161 (81.3%) | 52 (58.4%) | 53 (100%) | 56 (100%) | <0.001 | NA |
| Socioeconomic Factors | ||||||
| Income Below Federal Poverty Level (N=192) | 58 (30.2%) | 33 (38.8%) | 24 (47.1%) | 1 (1.8%) | <0.001 | <0.001 |
| Education (N=201) | <0.001 | <0.0011 | ||||
| Less than High School | 28 (13.9%) | 27 (29.3%) | 1 (1.9%) | 0 (0%) | ||
| High School Graduate or Some College | 87 (43.3%) | 40 (43.5%) | 36 (67.9%) | 11 (19.6%) | ||
| College Graduate | 86 (42.8%) | 25 (27.2%) | 16 (30.2%) | 45 (80.4%) | ||
| Healthcare Access | ||||||
| Specialist for Asthma Care | 106 (52.5%) | 43 (46.2%) | 25 (47.2%) | 38 (67.9%) | 0.01 | 0.03 |
| Insurance (N=198) | <0.001 | <0.001 | ||||
| Private | 72 (36.4%) | 18 (19.8%) | 9 (17.3%) | 45 (81.8%) | ||
| Public | 126 (63.6%) | 73 (80.2%) | 43 (82.7%) | 10 (18.2%) | ||
| Transportation Delayed Care | 11 (5.4%) | 5 (5.4%) | 6 (11.3%) | 0 (0.0%) | 0.16 | 0.011 |
| Markers of Asthma Control | ||||||
| Well-Control per ACT (N=194) | 123 (63.4%) | 55 (61.1%) | 23 (44.2%) | 45 (86.5%) | 0.001 | <0.001 |
| Use of Reliever Medication in Past 2 Weeks (N=200) | 114 (57.0%) | 54 (59.3%) | 38 (71.7%) | 22 (39.3%) | 0.02 | <0.001 |
| Use of Oral Corticosteroid in Past 3 Months | 22 (10.9%) | 11 (11.8%) | 6 (11.3%) | 5 (8.9%) | 0.58 | 0.68 |
| Markers of Asthma Treatment | ||||||
| Prescribed or Taken Controller Medication in Past 3 Months | 134 (66.3%) | 60 (64.5%) | 33 (62.3%) | 41 (73.2%) | 0.27 | 0.22 |
| Use of Controller Medication in Past 2 Weeks | 112 (55.4%) | 47 (50.5%) | 25 (47.2%) | 40 (71.4%) | 0.01 | 0.009 |
| ICS Days Used in Past 2 Weeks | 6.24 ± 6.93 | 5.68 ± 6.92 | 4.74 ± 6.86 | 8.59 ± 6.54 | 0.01 | 0.003 |
| Lung Function, FeNO and Atopy | ||||||
| ppFEV1 (N=142) | 97.16 ± 17.35 | 101.72 ± 17.27 | 86.54 ± 14.91 | 100.05 ± 15.08 | 0.61 | <0.001 |
| ppFVC (N=126) | 101.62 ± 16.59 | 105.82 ± 17.01 | 93.00 ± 14.74 | 103.04 ± 14.15 | 0.41 | 0.007 |
| FEV1/FVC (N=124) | 0.83 ± 0.08 | 0.83 ± 0.07 | 0.82 ± 0.08 | 0.83 ± 0.09 | 0.83 | 0.47 |
| Exhaled Nitric Oxide (ppb) (N=158) | 18.25 [10.50, 39.75] | 18.75 [10.88, 41.50] | 21.00 [12.00, 48.50] | 14.50 [9.50, 31.00] | 0.03 | 0.04 |
| Sensitized to ≥ 1 Allergen2 (N = 149) | 109 (73.2%) | 50 (72.5%) | 30 (81.1%) | 29 (67.4%) | 0.57 | 0.17 |
| Number of Allergens Sensitized To2 (N = 149) | 2.15 ± 1.85 | 1.96 ± 1.75 | 2.78 ± 2.07 | 1.91 ± 1.72 | 0.88 | 0.04 |
| Markers of Exacerbation | ||||||
| Asthma Related Urgent Care Visit in Past 12 Months | 93 (46.0%) | 42 (45.2%) | 29 (54.7%) | 22 (39.3%) | 0.12 | 0.01 |
ACT – asthma control test
ICS – inhaled corticosteroid
ppFEV1 – percent of predicted Forced Expiratory Volume in 1 second
ppFVC – percent of predicted Forced Vital Capacity
NA – statistical testing not possible due to small sample sizes
If “N” is not provided, then the full cohort was observed.
Fisher’s exact test
Allergens included: cat, dog, dust mite (Dermatophagoides pteronyssinus), American cockroach, German cockroach, and mountain cedar.
Mexican American and Black children experienced greater socioeconomic disadvantage than Non-Hispanic White children. More than one-third of Mexican American children and nearly half of Black children lived below the FPL, compared to less than 2% of Non-Hispanic White children. Nearly 30% of Mexican American parents/caregivers lacked a high school diploma, compared to 2% of Black and none of Non-Hispanic White parents/caregivers.
Healthcare access also varied by race and ethnicity. Fewer than half of Mexican American and Black children received asthma care from a specialist, compared to more than two-thirds of Non-Hispanic White children. The prevalence of private insurance was lower among Mexican American (19.8%) and Black children (17.3%) than among Non-Hispanic White children (81.8%). Transportation-related delays in asthma care were reported among Mexican American and Black families, but not among Non-Hispanic White families.
Among children with acceptable-quality spirometry, ppFEV1 and ppFVC (predicted using race-neutral reference equations), and FEV1/FVC, were similar between Mexican American and Non-Hispanic White children. Black children had significantly lower values for ppFEV1 and ppFVC than Non-Hispanic White children. Sensitivity analysis, including all spirometry grades (A-D), produced similar results. FeNO levels were higher among Mexican American and Black children compared to Non-Hispanic White children. Sensitization to at least one allergen did not differ by race or ethnicity, although Black children were sensitized to a greater number of allergens on average than Non-Hispanic White children. Asthma-related urgent care visits in the past 12 months were more common among Mexican American and Black children compared to non-Hispanic White children, though this was statistically significant only for Black versus Non-Hispanic White children.
Characteristics of Children by Asthma Control
Mexican American and Black children had poorer asthma control than Non-Hispanic White children. Well-controlled asthma (ACT ≥ 20) was observed in 61.1% of Mexican American children, 44.2% of Black children, and 86.5% of Non-Hispanic White children. Reliever medication use in the past two weeks was more common among Mexican American and Black children than among Non-Hispanic White children, whereas oral corticosteroid use in the past three months did not differ significantly by race or ethnicity.
Children with well-controlled asthma were more likely to be Non-Hispanic White, privately insured, and have parents/caregivers with higher educational attainment (Table II). In age and sex-adjusted models, both Mexican American (OR = 0.19, 95% CI = 0.07–0.46) and Black children (OR = 0.09, 95% CI = 0.03–0.24) had lower odds of well-controlled asthma compared to Non-Hispanic White children (Table III). Racial and ethnic disparities persisted after further adjustment for socioeconomic factors (Mexican American: OR = 0.27, 95% CI = 0.09–0.75; Black: OR = 0.13, 95% CI = 0.04–0.37), and healthcare access factors (Mexican American: OR = 0.26, 95% CI = 0.08–0.74; Black: OR = 0.13, 95% CI = 0.04–0.41). In fully adjusted models, the disparity was somewhat attenuated for Mexican American children (OR = 0.31, 95% CI = 0.10–0.93) and Black children (OR = 0.15, 95% CI = 0.05–0.49) and remained statistically significant, suggesting that differences in socioeconomic factors, and healthcare access factors do not meaningfully account for inequities in asthma control.
TABLE II.
Asthma Control by Sociodemographic Characteristics, Socioeconomic Factors, Asthma Treatment and Healthcare Access. Data represent the mean ± SD, median [IQR], or the number of participants (%).
| Total (N=194)1 | Not Well-Controlled Asthma (N=71) | Well-Controlled Asthma (N=123) | p-value | |
|---|---|---|---|---|
| Sociodemographic Characteristics | ||||
| Age (years) | 10.5 ± 3.38 | 9.9 ± 3.60 | 10.8 ± 3.22 | 0.11 |
| Male Sex | 128 (66.0%) | 42 (59.2%) | 86 (69.9%) | 0.13 |
| Race and Ethnicity | <0.001 | |||
| Mexican American | 90 (46.4%) | 35 (49.3%) | 55 (44.7%) | |
| Black | 52 (26.8%) | 29 (40.8%) | 23 (18.7%) | |
| Non-Hispanic White | 52 (26.8%) | 7 (9.9%) | 45 (36.6%) | |
| Preferred Language English (N=190) | 153 (78.9%) | 57 (80.3%) | 96 (78.0%) | 0.58 |
| Socioeconomic Factors | ||||
| Income Below Federal Poverty Level (N=193) | 57 (29.4%) | 25 (35.2%) | 32 (26.0%) | 0.13 |
| Education (N=193) | 0.002 | |||
| Less than High School | 26 (13.4%) | 13 (18.3%) | 13 (10.6%) | |
| High School Graduate or Some College | 86 (44.3%) | 40 (56.3%) | 46 (37.4%) | |
| College Graduate | 81 (41.8%) | 18 (25.4%) | 63 (51.2%) | |
| Healthcare Access | ||||
| Specialist for Asthma Care | 100 (51.5%) | 35 (49.3%) | 65 (52.8%) | 0.63 |
| Insurance (N=190) | 0.003 | |||
| Private | 67 (34.5%) | 15 (21.1%) | 52 (42.3%) | |
| Public | 123 (63.4%) | 54 (76.1%) | 69 (56.1%) | |
| Transportation Delayed Care | 10 (5.2%) | 5 (7.0%) | 5 (4.1%) | 0.50 |
| Markers of Asthma Treatment | ||||
| Use of Controller Medication in Past 2 Weeks | 108 (55.7%) | 34 (47.9%) | 74 (60.2%) | 0.10 |
| ICS Days Used in Past 2 Weeks (N=192) | 6.21 ± 6.93 | 5.58 ± 7.01 | 6.57 ± 6.88 | 0.34 |
| Lung Function, FeNO and Atopy | ||||
| ppFEV1 (N=141) | 97.06 ± 17.37 | 94.95 ± 19.52 | 98.46 ± 15.76 | 0.26 |
| ppFVC (N=125) | 101.58 ± 16.65 | 99.8 ± 17.88 | 102.72 ± 15.82 | 0.35 |
| FEV1/FVC (N=123) | 0.83 ± 0.08 | 0.82 ± 0.09 | 0.83 ± 0.07 | 0.59 |
| Exhaled Nitric Oxide (ppb) (N=158) | 18.25 [10.50, 39.75] | 17.00 [10.50, 39.62] | 19.75 [10.00, 38.25] | 0.57 |
| Sensitized to ≥ 1 Allergen2 (N = 145) | 108 (55.7%) | 30 (42.3%) | 78 (63.4%) | 0.66 |
| Number of Allergens Sensitized To2 (N = 145) | 2.18 ± 1.84 | 1.96 ± 2.01 | 2.28 ± 1.76 | 0.90 |
| Markers of Exacerbation | ||||
| Asthma Related Urgent Care Visit in Past 12 Months | 91 (46.9%) | 39 (54.9%) | 52 (42.3%) | 0.09 |
Of individuals who had score recorded for asthma control test
Allergens included: cat, dog, dust mite (Dermatophagoides pteronyssinus), American cockroach, German cockroach, and mountain cedar.
If “N” is not provided, then the full cohort was observed.
TABLE III.
Association of Race/Ethnicity and Well-Controlled Asthma among Children with Persistent Asthma in Central Texas.
| Age and Sex | Age, Sex and Socioeconomic Factors1 | Age, Sex and Healthcare Access Factors2 | Age, Sex, Socioeconomic and Healthcare Access Factors1,2 | |||||
|---|---|---|---|---|---|---|---|---|
| AOR | 95% CI | AOR | 95% CI | AOR | 95% CI | AOR | 95% CI | |
| Race and Ethnicity | ||||||||
| Non-Hispanic White | Ref | --- | Ref | --- | Ref | --- | Ref | --- |
| Mexican American | 0.19* | 0.07–0.46 | 0.27* | 0.09–0.75 | 0.26* | 0.08–0.74 | 0.31* | 0.10–0.93 |
| Black | 0.09* | 0.03–0.24 | 0.13* | 0.04–0.37 | 0.13* | 0.04–0.41 | 0.15* | 0.05–0.49 |
adjusted for income above federal poverty level and parental educational attainment
adjusted for insurance type, asthma provider type and if transportation delayed asthma care in past 12 months
statistically significant to a level of p-value < 0.05
Characteristics of Children by Controller Medication Use
Controller medication prescription or use in the past three months did not differ by race or ethnicity. However, recent use (past two weeks) was lower among Mexican American (50.5%) and Black children (47.2%) than among Non-Hispanic White children (71.4%). The frequency of controller medication use in the past two weeks was also lower among Mexican American and Black children compared to Non-Hispanic White children.
Children using controller medications were more likely to have college-educated parents/caregivers, specialist asthma care, and private insurance, and were less likely to live below the FPL or use reliever medications in the past two weeks (Table IV). In age and sex-adjusted models, Mexican American (OR = 0.42, 95% CI = 0.20–0.85) and Black children (OR = 0.36, 95% CI = 0.16–0.79) had significantly lower odds of controller medication use than Non-Hispanic White children (Table V). These disparities were attenuated and no longer statistically significant after further adjustment for socioeconomic factors and healthcare access factors, indicating that differences in these domains accounted for part of the disparity in controller medication use.
TABLE IV.
Controller Medication Use in Past Two Weeks by Sociodemographic Characteristics, Asthma Control and Healthcare Access. Data represent the mean ± SD, median [IQR], or the number of participants (%).
| Total (N=202) | Did not use controller medication (N=90) | Used controller medication (N=112) | p-value | |
|---|---|---|---|---|
| Sociodemographic Characteristics | ||||
| Age (years) | 10.5 ± 3.40 | 10.7 ± 3.51 | 10.4 ± 3.31 | 0.49 |
| Male Sex | 134 (66.3%) | 63 (70.0%) | 71 (63.4%) | 0.32 |
| Race and Ethnicity | 0.02 | |||
| Mexican American | 93 (46.0%) | 46 (51.1%) | 47 (42.0%) | |
| Black | 53 (26.2%) | 28 (31.1%) | 25 (22.3%) | |
| Non-Hispanic White | 56 (27.7%) | 16 (17.8%) | 40 (35.7%) | |
| Preferred Language English (N=198) | 161 (79.7%) | 68 (75.6%) | 93 (83.0%) | 0.11 |
| Socioeconomic Factors | ||||
| Income Below Federal Poverty Level (N=192) | 58 (28.7%) | 32 (35.6%) | 26 (23.2%) | 0.05 |
| Education (N=201) | 0.01 | |||
| Less than High School | 28 (13.9%) | 11 (12.2%) | 17 (15.2%) | |
| High School Graduate or Some College | 87 (43.1%) | 49 (54.4%) | 38 (33.9%) | |
| College Graduate | 86 (42.6%) | 30 (33.3%) | 56 (50.0%) | |
| Healthcare Access | ||||
| Specialist for Asthma Care | 106 (52.5%) | 28 (31.1%) | 78 (69.6%) | <0.001 |
| Insurance (N=198) | 0.007 | |||
| Private | 72 (35.6%) | 23 (25.6%) | 49 (43.8%) | |
| Public | 126 (62.4%) | 65 (72.2%) | 61 (54.5%) | |
| Transportation Delayed Care | 11 (5.4%) | 7 (7.8%) | 4 (3.6%) | 0.221 |
| Markers of Asthma Control | ||||
| Well-Controlled per ACT (N=194) | 123 (60.9%) | 49 (54.4%) | 74 (66.1%) | 0.09 |
| Use of Reliever Medication in Past 2 Weeks (N=200) | 114 (56.4%) | 59 (65.6%) | 55 (49.1%) | 0.01 |
| Use of Oral Corticosteroid in Past 3 Months | 22 (10.9%) | 8 (8.9%) | 14 (12.5%) | 0.41 |
| Lung Function, FeNO and Atopy | ||||
| ppFEV1 (N=142) | 97.16 ± 17.35 | 96.04 ± 20.28 | 98.16 ± 14.29 | 0.48 |
| ppFVC (N=126) | 101.62 ± 16.59 | 100.27 ± 18.23 | 102.67 ± 15.24 | 0.43 |
| FEV1/FVC (N=124) | 0.83 ± 0.08 | 0.82 ± 0.08 | 0.83 ± 0.08 | 0.64 |
| Exhaled Nitric Oxide (ppb) (N=158) | 18.25 [10.50, 39.75] | 19.75 [10.50, 43.62] | 17.50 [10.38, 31.75] | 0.33 |
| Sensitized to ≥ 1 Allergen2 (N = 149) | 109 (54.0%) | 48 (53.3%) | 61 (54.5%) | 0.66 |
| Number of Allergens Sensitized To2 (N = 149) | 2.15 ± 1.85 | 2.31 ± 1.9 | 2.02 ± 1.81 | 0.57 |
| Markers of Exacerbation | ||||
| Asthma Related Urgent Care Visit in Past 12 Months | 93 (46.0%) | 38 (42.2%) | 55 (49.1%) | 0.33 |
Fisher’s exact test
Allergens included: cat, dog, dust mite (Dermatophagoides pteronyssinus), American cockroach, German cockroach, and mountain cedar.
If “N” is not provided, then the full cohort was observed.
TABLE V.
Association of Race/Ethnicity and Controller Medication Use in Past 2 Weeks among Children with Persistent Asthma in Central Texas.
| Age and Sex | Age, Sex and Socioeconomic Factors1 | Age, Sex, and Healthcare Access Factors2 | Age, Socioeconomic and Healthcare Access Factors1,2 | |||||
|---|---|---|---|---|---|---|---|---|
| AOR | 95% CI | AOR | 95% CI | AOR | 95% CI | AOR | 95% CI | |
| Race and Ethnicity | ||||||||
| Non-Hispanic White | Ref | --- | Ref | --- | Ref | --- | Ref | --- |
| Mexican American | 0.42* | 0.20–0.85 | 0.50 | 0.22–1.10 | 0.59 | 0.23–1.44 | 0.69 | 0.26–1.83 |
| Black | 0.36* | 0.16–0.79 | 0.47 | 0.19–1.20 | 0.51 | 0.18–1.37 | 0.63 | 0.22–1.82 |
adjusted for income above federal poverty level and parental educational attainment
adjusted for insurance type, asthma provider type and if transportation delayed asthma care in past 12 months
statistically significant to a level of p-value < 0.05
DISCUSSION
In this cohort of racially and ethnically diverse children with persistent asthma in Central Texas, Mexican American children were significantly less likely than non-Hispanic White children to have well-controlled asthma and to use controller medications. However, the disparity in asthma control was more pronounced between Black and non-Hispanic White children. Mexican American and Black children had similar disparities in controller medication use compared with non-Hispanic White children. Racial and ethnic disparities in controller medication use were partially explained by socioeconomic factors and health care access. In contrast, disparities in asthma control were not meaningfully explained by socioeconomic factors and health care access.
Disparities in asthma control between Mexican American and Non-Hispanic White children persisted after adjusting for household income, parent education, insurance type, asthma provider type, and transportation barriers, suggesting that other factors underlie this disparity. Environmental and contextual exposures in the neighborhood and home environment may also play a critical role(28, 29). Hispanic/Latinx populations are more frequently exposed to environmental risk factors for asthma than non-Hispanic White populations, including ambient air pollution, fossil fuel combustion, mold, and pest allergens(30–32). Although we found comparable levels of atopic sensitization across racial and ethnic groups prior, research suggests that sensitization to pest allergens may be more prevalent in Mexican American populations, potentially exacerbating the effects of indoor exposures(33, 34). Compared to non-Hispanic White population, Hispanic/Latinx populations are also more likely to reside in disadvantaged neighborhoods where violence and disorder are more common(35). Neighborhood violence and disorder have been linked to asthma symptoms in children(36). Additionally, upper respiratory viral infections—the predominant triggers of asthma exacerbations in children(37)—have been found to be more prevalent in Mexican American children compared to Non-Hispanic White children(38). Addressing environmental exposures, neighborhood stressors, and risk of upper respiratory viral infections in homes and schools may be just as critical to managing asthma as adequate treatment of Mexican American children(36, 39–41).
Disparities in controller medication use between Mexican American and Non-Hispanic White children were attenuated after adjusting for household income, parent education, insurance type, asthma provider type, and transportation barriers, suggesting that these factors help to explain disparities in controller medication use. However, the magnitude of the fully adjusted odds ratio suggests that these traditional indicators of socioeconomic status and healthcare access do not fully explain the disparities in controller medication use. Other factors likely disrupt steps in the pathway between experiencing uncontrolled asthma and controller medication use. For example, perceived discrimination and language barriers may affect whether families seek care for uncontrolled asthma; health literacy may influence how asthma control is interpreted; out-of-pocket costs may affect whether families fill prescriptions; and cultural beliefs may affect consistent use of controller medications(42). Other studies have shown that cultural beliefs and practices, such as concerns about medication side effects and a reliance on alternative medicines, may hinder effective asthma management in Latinx/Hispanic communities(43–45). These findings underscore the need to better understand the relative importance of cultural and systemic barriers to asthma control and treatment in Mexican American children. With an understanding of which treatment barriers are most important, they may be prioritized and addressed through targeted interventions. Interventions that have been shown to improve controller medication use include patient education programs(46, 47), digital tools such as smart inhalers, reminders, and telemedicine support(48–50), and system-level quality improvement initiatives(51). Other interventions may involve improving health literacy, reducing treatment costs, or providing culturally tailored asthma education(52, 53).
Although socioeconomic disadvantage and differences in healthcare access contributed to the disparities observed across race and ethnicity, they did not fully explain them. This suggests that additional unmeasured factors, such as environmental exposures, provider prescribing patterns, or adherence-related barriers, may also influence asthma control and treatment among Mexican American and Black children.
The observed higher prevalence and number of IgE sensitizations, along with elevated FeNO, in Black compared with White children with asthma is well documented(54, 55). Similar to Black children, FeNO values were higher in Mexican American children than in Non-Hispanic White children. While this observation may reflect differences in the prevalence of Type 2 asthma between Mexican American and non-Hispanic White participants, the similar prevalence and number of IgE sensitizations between these two groups suggest that the higher FeNO levels in Mexican American participants may reflect undertreatment with inhaled corticosteroids. This observation is consistent with the broader finding of poorer asthma control and lower controller medication use among Mexican American children.
Several limitations of this study should be considered. First, its cross-sectional design limits our ability to infer causal relationships between race and ethnicity, socioeconomic status, healthcare access, asthma control, and medication use. Longitudinal studies would provide stronger support for conclusions about causality. Additionally, because this is a cross-sectional study, there was not prospective data to evaluate the association between current uncontrolled asthma and future asthma-related urgent visits. Second, while controller medication use in the past two weeks was based on reported use aided by a direct observation of the medications, the three-month measure did not distinguish between prescription and actual use, limiting our ability to draw conclusions about prescription versus adherence. This could be investigated in future studies in which data are collected on prescription and separately, on adherence. Separately, because our screening survey also included parent-reported ICS use in the past two weeks, our findings are generalizable to a population with persistent asthma defined by parent report and may not be generalizable to populations defined by prescription fill data. Third, some healthcare access variables (e.g., insurance type, specialist care, transportation barriers) may themselves be consequences of socioeconomic disadvantage. As a result, adjusting for socioeconomic status in our regression models could lead to overadjustment for healthcare access. However, because our primary interest was in estimating racial and ethnic disparities in asthma control and treatment—rather than the independent effects of socioeconomic or healthcare access factors—this potential overadjustment would not impact our main conclusions. Lastly, our geographic focus on Central Texas may limit the generalizability to other regions of the US that are characterized by different environmental exposures and cultural contexts. However, our findings align with nationally representative studies showing disparities in asthma morbidity between Mexican American and Non-Hispanic White children and between Black and Non-Hispanic White children(3, 13, 56, 57).
Our findings highlight striking disparities in asthma control and treatment between Mexican American and Non-Hispanic White children—disparities that approach those observed between Black and Non-Hispanic White children. Compared to Non-Hispanic White children, Mexican American children had a greater reliance on reliever medications, poorer asthma control, lower controller medication use, and greater pulmonary eosinophilic inflammation. While socioeconomic and healthcare access factors contributed to racial and ethnic disparities in controller medication usage, they contributed much less to this disparity in asthma control. Recognizing Mexican American children as a distinct and underserved group in asthma care should be considered when developing interventions that reduce racial and ethnic disparities in asthma morbidity.
Clinical Implication:
Mexican American children have not traditionally been recognized as having excess asthma burden. These findings highlight their lower likelihood of well-controlled asthma and controller medication use compared to non-Hispanic White children.
Acknowledgements
We would like to thank Maya Beesley, Ian Chiu, Fernando Garcia, Lizzy Keiger, and Sabrina Rosario for their contributions to data collection and study coordination. We would also like to acknowledge the health care organizations, including CommUnity Care, that contributed to this study’s recruitment efforts.
Funding
Preparation of this work was supported by NIH grants T32HL140290 and P2CHD042849 (Micheals); K24AI114769, R01 ES035131, R01 ES034803 (Matsui) as well as core funds from the Dell Medical School at The University of Texas at Austin (Bhavnani). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations
- ACT
Asthma Control Test
- CHIP
Children’s Health Insurance Program
- FPL
Federal Poverty Level
- ICS
Inhaled Corticosteroids
- TexHALE
Texas Home Assessment of Asthma and Lung Exposures
Footnotes
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Conflict of Interest Statement
The authors declare no conflicts of interest related to this work.
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