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. 2005 Mar-Apr;120(2):109–116. doi: 10.1177/003335490512000203

Rethinking race/ethnicity, income, and childhood asthma: racial/ethnic disparities concentrated among the very poor.

Lauren A Smith 1, Juliet L Hatcher-Ross 1, Richard Wertheimer 1, Robert S Kahn 1
PMCID: PMC1497701  PMID: 15842111

Abstract

OBJECTIVE: Past studies of the prevalence of childhood asthma have yielded conflicting findings as to whether racial/ethnic disparities remain after other factors, such as income, are taken into account. The objective of this study was to examine the association of race/ethnicity and family income with the prevalence of childhood asthma and to assess whether racial/ethnic disparities vary by income strata. METHODS: Cross-sectional data on 14,244 children aged <18 years old in the 1997 National Health Interview Survey were examined. The authors used logistic regression to analyze the independent and joint effects of race/ethnicity and income-to-federal poverty level (FPL) ratio, adjusting for demographic covariates. The main outcome measure was parental report of the child having ever been diagnosed with asthma. RESULTS: Bivariate analyses, based on weighted percentages, revealed that asthma was more prevalent among non-Hispanic black children (13.6%) than among non-Hispanic white children (11.2%; p<0.01), but the prevalence of asthma did not differ significantly between Hispanic children (10.1%) and non-Hispanic white children (11.2%; p=0.13). Overall, non-Hispanic black children were at higher risk for asthma than non-Hispanic white children (adjusted odds ratio [OR]=1.20; 95% confidence interval [CI] 1.03, 1.40), after adjustment for sociodemographic variables, including the ratio of annual family income to the FPL. Asthma prevalence did not differ between Hispanic children and non-Hispanic white children in adjusted analyses (adjusted OR=0.85; 95% CI 0.71, 1.02). Analyses stratified by income revealed that only among children from families with incomes less than half the FPL did non-Hispanic black children have a higher risk of asthma than non-Hispanic white children (adjusted OR=1.99; 95% CI 1.09, 3.64). No black vs. white differences existed at other income levels. Subsequent analyses of these very poor children that took into account additional potentially explanatory variables did not attenuate the higher asthma risk for very poor non-Hispanic black children relative to very poor non-Hispanic white children. CONCLUSIONS: Non-Hispanic black children were at substantially higher risk of asthma than non-Hispanic white children only among the very poor. The concentration of racial/ethnic differences only among the very poor suggests that patterns of social and environmental exposures must overshadow any hypothetical genetic risk.

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Selected References

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  1. Akinbami Lara J., LaFleur Bonnie J., Schoendorf Kenneth C. Racial and income disparities in childhood asthma in the United States. Ambul Pediatr. 2002 Sep-Oct;2(5):382–387. doi: 10.1367/1539-4409(2002)002<0382:raidic>2.0.co;2. [DOI] [PubMed] [Google Scholar]
  2. Aligne C. A., Auinger P., Byrd R. S., Weitzman M. Risk factors for pediatric asthma. Contributions of poverty, race, and urban residence. Am J Respir Crit Care Med. 2000 Sep;162(3 Pt 1):873–877. doi: 10.1164/ajrccm.162.3.9908085. [DOI] [PubMed] [Google Scholar]
  3. Bacalo A., Kivity S., Heno N., Greif Z., Greif J., Topilsky M. Blood transfusion and lung function in children with thalassemia major. Chest. 1992 Feb;101(2):362–365. doi: 10.1378/chest.101.2.362. [DOI] [PubMed] [Google Scholar]
  4. Braveman P., Cubbin C., Marchi K., Egerter S., Chavez G. Measuring socioeconomic status/position in studies of racial/ethnic disparities: maternal and infant health. Public Health Rep. 2001 Sep-Oct;116(5):449–463. doi: 10.1093/phr/116.5.449. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Butz A. M., Eggleston P., Huss K., Kolodner K., Rand C. Nebulizer use in inner-city children with asthma: morbidity, medication use, and asthma management practices. Arch Pediatr Adolesc Med. 2000 Oct;154(10):984–990. doi: 10.1001/archpedi.154.10.984. [DOI] [PubMed] [Google Scholar]
  6. Carr W., Zeitel L., Weiss K. Variations in asthma hospitalizations and deaths in New York City. Am J Public Health. 1992 Jan;82(1):59–65. doi: 10.2105/ajph.82.1.59. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Carter-Pokras O. D., Gergen P. J. Reported asthma among Puerto Rican, Mexican-American, and Cuban children, 1982 through 1984. Am J Public Health. 1993 Apr;83(4):580–582. doi: 10.2105/ajph.83.4.580. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cooper Richard S., Kaufman Jay S., Ward Ryk. Race and genomics. N Engl J Med. 2003 Mar 20;348(12):1166–1170. doi: 10.1056/NEJMsb022863. [DOI] [PubMed] [Google Scholar]
  9. Cooper W. O., Hickson G. B. Corticosteroid prescription filling for children covered by Medicaid following an emergency department visit or a hospitalization for asthma. Arch Pediatr Adolesc Med. 2001 Oct;155(10):1111–1115. doi: 10.1001/archpedi.155.10.1111. [DOI] [PubMed] [Google Scholar]
  10. Crain E. F., Kercsmar C., Weiss K. B., Mitchell H., Lynn H. Reported difficulties in access to quality care for children with asthma in the inner city. Arch Pediatr Adolesc Med. 1998 Apr;152(4):333–339. doi: 10.1001/archpedi.152.4.333. [DOI] [PubMed] [Google Scholar]
  11. Crain E. F., Weiss K. B., Bijur P. E., Hersh M., Westbrook L., Stein R. E. An estimate of the prevalence of asthma and wheezing among inner-city children. Pediatrics. 1994 Sep;94(3):356–362. [PubMed] [Google Scholar]
  12. Cunningham J., Dockery D. W., Speizer F. E. Race, asthma, and persistent wheeze in Philadelphia schoolchildren. Am J Public Health. 1996 Oct;86(10):1406–1409. doi: 10.2105/ajph.86.10.1406. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Diette G. B., Skinner E. A., Markson L. E., Algatt-Bergstrom P., Nguyen T. T., Clark R. D., Wu A. W. Consistency of care with national guidelines for children with asthma in managed care. J Pediatr. 2001 Jan;138(1):59–64. doi: 10.1067/mpd.2001.109600. [DOI] [PubMed] [Google Scholar]
  14. Duncan G. J., Brooks-Gunn J., Klebanov P. K. Economic deprivation and early childhood development. Child Dev. 1994 Apr;65(2 Spec No):296–318. [PubMed] [Google Scholar]
  15. Finkelstein J. A., Brown R. W., Schneider L. C., Weiss S. T., Quintana J. M., Goldmann D. A., Homer C. J. Quality of care for preschool children with asthma: the role of social factors and practice setting. Pediatrics. 1995 Mar;95(3):389–394. [PubMed] [Google Scholar]
  16. Finkelstein Jonathan A., Lozano Paula, Farber Harold J., Miroshnik Irina, Lieu Tracy A. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002 Jun;156(6):562–567. doi: 10.1001/archpedi.156.6.562. [DOI] [PubMed] [Google Scholar]
  17. Flores G., Bauchner H., Feinstein A. R., Nguyen U. S. The impact of ethnicity, family income, and parental education on children's health and use of health services. Am J Public Health. 1999 Jul;89(7):1066–1071. doi: 10.2105/ajph.89.7.1066. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Gelber L. E., Seltzer L. H., Bouzoukis J. K., Pollart S. M., Chapman M. D., Platts-Mills T. A. Sensitization and exposure to indoor allergens as risk factors for asthma among patients presenting to hospital. Am Rev Respir Dis. 1993 Mar;147(3):573–578. doi: 10.1164/ajrccm/147.3.573. [DOI] [PubMed] [Google Scholar]
  19. Goodman D. C., Stukel T. A., Chang C. H. Trends in pediatric asthma hospitalization rates: regional and socioeconomic differences. Pediatrics. 1998 Feb;101(2):208–213. doi: 10.1542/peds.101.2.208. [DOI] [PubMed] [Google Scholar]
  20. Grant E. N., Lyttle C. S., Weiss K. B. The relation of socioeconomic factors and racial/ethnic differences in US asthma mortality. Am J Public Health. 2000 Dec;90(12):1923–1925. doi: 10.2105/ajph.90.12.1923. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hahn B. A. Children's health: racial and ethnic differences in the use of prescription medications. Pediatrics. 1995 May;95(5):727–732. [PubMed] [Google Scholar]
  22. Halterman J. S., Yoos H. L., Sidora K., Kitzman H., McMullen A. Medication use and health care contacts among symptomatic children with asthma. Ambul Pediatr. 2001 Sep-Oct;1(5):275–279. doi: 10.1367/1539-4409(2001)001<0275:muahcc>2.0.co;2. [DOI] [PubMed] [Google Scholar]
  23. Jones C. P. Invited commentary: "race," racism, and the practice of epidemiology. Am J Epidemiol. 2001 Aug 15;154(4):299–306. doi: 10.1093/aje/154.4.299. [DOI] [PubMed] [Google Scholar]
  24. Kaplan Judith B., Bennett Trude. Use of race and ethnicity in biomedical publication. JAMA. 2003 May 28;289(20):2709–2716. doi: 10.1001/jama.289.20.2709. [DOI] [PubMed] [Google Scholar]
  25. Kaufman J. S., Cooper R. S., McGee D. L. Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race. Epidemiology. 1997 Nov;8(6):621–628. [PubMed] [Google Scholar]
  26. Krieger N. The ostrich, the albatross, and public health: an ecosocial perspective--or why an explicit focus on health consequences of discrimination and deprivation is vital for good science and public health practice. Public Health Rep. 2001 Sep-Oct;116(5):419–423. doi: 10.1093/phr/116.5.419. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. LaVeist T. A. On the study of race, racism, and health: a shift from description to explanation. Int J Health Serv. 2000;30(1):217–219. doi: 10.2190/LKDF-UJQ5-W1KU-GLR1. [DOI] [PubMed] [Google Scholar]
  28. Lang D. M., Polansky M. Patterns of asthma mortality in Philadelphia from 1969 to 1991. N Engl J Med. 1994 Dec 8;331(23):1542–1546. doi: 10.1056/NEJM199412083312302. [DOI] [PubMed] [Google Scholar]
  29. Lester L. A., Rich S. S., Blumenthal M. N., Togias A., Murphy S., Malveaux F., Miller M. E., Dunston G. M., Solway J., Wolf R. L. Ethnic differences in asthma and associated phenotypes: collaborative study on the genetics of asthma. J Allergy Clin Immunol. 2001 Sep;108(3):357–362. doi: 10.1067/mai.2001.117796. [DOI] [PubMed] [Google Scholar]
  30. Lieu Tracy A., Lozano Paula, Finkelstein Jonathan A., Chi Felicia W., Jensvold Nancy G., Capra Angela M., Quesenberry Charles P., Selby Joe V., Farber Harold J. Racial/ethnic variation in asthma status and management practices among children in managed medicaid. Pediatrics. 2002 May;109(5):857–865. doi: 10.1542/peds.109.5.857. [DOI] [PubMed] [Google Scholar]
  31. Miller J. E. The effects of race/ethnicity and income on early childhood asthma prevalence and health care use. Am J Public Health. 2000 Mar;90(3):428–430. doi: 10.2105/ajph.90.3.428. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Newacheck P. W., Halfon N. Prevalence, impact, and trends in childhood disability due to asthma. Arch Pediatr Adolesc Med. 2000 Mar;154(3):287–293. doi: 10.1001/archpedi.154.3.287. [DOI] [PubMed] [Google Scholar]
  33. Ortega A. N., Belanger K. D., Paltiel A. D., Horwitz S. M., Bracken M. B., Leaderer B. P. Use of health services by insurance status among children with asthma. Med Care. 2001 Oct;39(10):1065–1074. doi: 10.1097/00005650-200110000-00004. [DOI] [PubMed] [Google Scholar]
  34. Pachter Lee M., Weller Susan C., Baer Roberta D., de Alba Garcia Javier E. Garcia, Trotter Robert T., 2nd, Glazer Mark, Klein Robert. Variation in asthma beliefs and practices among mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans. J Asthma. 2002 Apr;39(2):119–134. doi: 10.1081/jas-120002193. [DOI] [PubMed] [Google Scholar]
  35. Platts-Mills T. A. How environment affects patients with allergic disease: indoor allergens and asthma. Ann Allergy. 1994 Apr;72(4):381–384. [PubMed] [Google Scholar]
  36. Platts-Mills T. A., Ward G. W., Jr, Sporik R., Gelber L. E., Chapman M. D., Heymann P. W. Epidemiology of the relationship between exposure to indoor allergens and asthma. Int Arch Allergy Appl Immunol. 1991;94(1-4):339–345. doi: 10.1159/000235398. [DOI] [PubMed] [Google Scholar]
  37. Rivara F., Finberg L. Use of the terms race and ethnicity. Arch Pediatr Adolesc Med. 2001 Feb;155(2):119–119. doi: 10.1001/archpedi.155.2.119. [DOI] [PubMed] [Google Scholar]
  38. Roberts Eric M. Does your child have asthma? Parent reports and medication use for pediatric asthma. Arch Pediatr Adolesc Med. 2003 May;157(5):449–455. doi: 10.1001/archpedi.157.5.449. [DOI] [PubMed] [Google Scholar]
  39. Roberts Eric M. Racial and ethnic disparities in childhood asthma diagnosis: the role of clinical findings. J Natl Med Assoc. 2002 Apr;94(4):215–223. [PMC free article] [PubMed] [Google Scholar]
  40. Rosenstreich D. L., Eggleston P., Kattan M., Baker D., Slavin R. G., Gergen P., Mitchell H., McNiff-Mortimer K., Lynn H., Ownby D. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med. 1997 May 8;336(19):1356–1363. doi: 10.1056/NEJM199705083361904. [DOI] [PubMed] [Google Scholar]
  41. Sarpong S. B., Hamilton R. G., Eggleston P. A., Adkinson N. F., Jr Socioeconomic status and race as risk factors for cockroach allergen exposure and sensitization in children with asthma. J Allergy Clin Immunol. 1996 Jun;97(6):1393–1401. doi: 10.1016/s0091-6749(96)70209-9. [DOI] [PubMed] [Google Scholar]
  42. Schleicher N. C., Koziol J. A., Christiansen S. C. Asthma mortality rates among California youths. J Asthma. 2000 May;37(3):259–265. doi: 10.3109/02770900009055448. [DOI] [PubMed] [Google Scholar]
  43. Sporik R., Holgate S. T., Platts-Mills T. A., Cogswell J. J. Exposure to house-dust mite allergen (Der p I) and the development of asthma in childhood. A prospective study. N Engl J Med. 1990 Aug 23;323(8):502–507. doi: 10.1056/NEJM199008233230802. [DOI] [PubMed] [Google Scholar]
  44. Stassen H. H., Scharfetter C. Oligogenic approaches to the predisposition of asthma in ethnically diverse populations. Genet Epidemiol. 2001;21 (Suppl 1):S284–S289. doi: 10.1002/gepi.2001.21.s1.s284. [DOI] [PubMed] [Google Scholar]
  45. Vach W., Blettner M. Biased estimation of the odds ratio in case-control studies due to the use of ad hoc methods of correcting for missing values for confounding variables. Am J Epidemiol. 1991 Oct 15;134(8):895–907. doi: 10.1093/oxfordjournals.aje.a116164. [DOI] [PubMed] [Google Scholar]
  46. Warman K. L., Silver E. J., McCourt M. P., Stein R. E. How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? National Heart, Lung, and Blood Institute. Pediatrics. 1999 Feb;103(2):422–427. doi: 10.1542/peds.103.2.422. [DOI] [PubMed] [Google Scholar]
  47. Weitzman M., Gortmaker S. L., Sobol A. M., Perrin J. M. Recent trends in the prevalence and severity of childhood asthma. JAMA. 1992 Nov 18;268(19):2673–2677. [PubMed] [Google Scholar]
  48. Weitzman M., Gortmaker S., Sobol A. Racial, social, and environmental risks for childhood asthma. Am J Dis Child. 1990 Nov;144(11):1189–1194. doi: 10.1001/archpedi.1990.02150350021016. [DOI] [PubMed] [Google Scholar]
  49. Williams D. R., Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001 Sep-Oct;116(5):404–416. doi: 10.1093/phr/116.5.404. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Williams D. R. Race and health: basic questions, emerging directions. Ann Epidemiol. 1997 Jul;7(5):322–333. doi: 10.1016/s1047-2797(97)00051-3. [DOI] [PubMed] [Google Scholar]
  51. Willies-Jacobo L. J., Denson-Lino J. M., Rosas A., O'Connor R. D., Wilson N. W. Socioeconomic status and allergy in children with asthma. J Allergy Clin Immunol. 1993 Oct;92(4):630–632. [PubMed] [Google Scholar]
  52. Wissow L. S., Gittelsohn A. M., Szklo M., Starfield B., Mussman M. Poverty, race, and hospitalization for childhood asthma. Am J Public Health. 1988 Jul;78(7):777–782. doi: 10.2105/ajph.78.7.777. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Wright R. J., Steinbach S. F. Violence: an unrecognized environmental exposure that may contribute to greater asthma morbidity in high risk inner-city populations. Environ Health Perspect. 2001 Oct;109(10):1085–1089. doi: 10.1289/ehp.011091085. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Xie H. G., Stein C. M., Kim R. B., Xiao Z. S., He N., Zhou H. H., Gainer J. V., Brown N. J., Haines J. L., Wood A. J. Frequency of functionally important beta-2 adrenoceptor polymorphisms varies markedly among African-American, Caucasian and Chinese individuals. Pharmacogenetics. 1999 Aug;9(4):511–516. [PubMed] [Google Scholar]
  55. Xu J., Meyers D. A., Ober C., Blumenthal M. N., Mellen B., Barnes K. C., King R. A., Lester L. A., Howard T. D., Solway J. Genomewide screen and identification of gene-gene interactions for asthma-susceptibility loci in three U.S. populations: collaborative study on the genetics of asthma. Am J Hum Genet. 2001 May 10;68(6):1437–1446. doi: 10.1086/320589. [DOI] [PMC free article] [PubMed] [Google Scholar]

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