Abstract
This cross-sectional study examines data from the Pediatric Eczema Elective Registry to assess associations of race/ethnicity with school absences attributed to atopic dermatitis in US school-aged children (6 to 17 years).
Atopic dermatitis (AD) affects up to 20% of children and is more common among black children.1 An association of AD with school absenteeism has been suggested.2 In this cross-sectional study, we examined AD-related school absences by race/ethnicity.
Methods
We used baseline data from children enrolled into the US-based Pediatric Eczema Elective Registry (PEER) between November 25, 2004, and July 18, 2017. All children were aged 2 to 17 years and had a physician-confirmed AD diagnosis. Details of PEER have been previously reported.3 On registry enrollment, children or their caregivers completed a questionnaire collecting information about demographic characteristics, medical conditions, AD history and treatment, and number of school days missed owing to AD (0, 1-5, 6-10, or >10) in the preceding 6-month period. Atopic dermatitis control in the same 6-month period was also reported by the child or caregiver as complete, good, limited, or uncontrolled. In this study, self-reported race/ethnicity, categorized as non-Hispanic white, non-Hispanic black, Hispanic, or other, was the primary explanatory variable. The primary outcome was reporting of 6 or more school days missed owing to AD in the previous 6 months, which approximates the US Department of Education’s definition of chronic school absenteeism. The association between race/ethnicity and at least 6 school absences was assessed using logistic regression, adjusting for sociodemographic factors, AD control, comorbid atopic disorders, and health care utilization. Children not enrolled in school or day care were excluded. Caregivers for participants in PEER provided informed consent; the present analysis was granted exempt status by the University of Pennsylvania Institutional Review Board owing to the use of deidentified data.
Results
In total, 8015 children were enrolled. Among these, 4273 (53.3%) were girls; median (interquartile range [IQR]) age was 6.6 (3.9-10.4) years; and 4079 (50.9%) identified as non-Hispanic black, 2576 (32.1%) as non-Hispanic white and 851 (10.6%) as Hispanic. Annual household income differed across racial/ethnic groups; a greater proportion of non-Hispanic black and Hispanic children lived in households with reported incomes below $50 000 (Table 1). Black and Hispanic children were also more likely to report uncontrolled AD. Overall, 4835 (60.3%) children used topical steroids in the last 6 months. Among the 7272 children enrolled in school or day care, 241 (3.3%) missed 6 or more days in the last 6 months. Non-Hispanic black (adjusted odds ratio [aOR] 1.49; 95% CI, 1.01-2.18) and Hispanic (aOR, 3.41; 95% CI, 2.16-5.38) children had higher adjusted odds of having at least 6 school absences compared with non-Hispanic white children (Table 2). Younger age (aOR, 0.95; 95% CI, 0.90-0.999); household income between $50 000 and $99 999 (aOR, 0.55; 95% CI, 0.31-0.97); uncontrolled AD (aOR, 6.36; 95% CI, 2.71-14.89); longer duration of AD (aOR, 1.07; 95% CI, 1.01-1.13); and comorbid asthma (aOR, 1.78; 95% CI, 1.31-2.40) or allergic rhinitis (aOR, 2.03; 95% CI, 1.35-3.05) were significantly associated with 6 or more absences (Table 2).
Table 1. Baseline Patient Characteristics by Race/Ethnicity.
| Characteristic | White non-Hispanic (n = 2576) | Black non-Hispanic (n = 4079) | Hispanic (n = 851) | Other Race/Ethnicity (n = 507)a | P Valueb |
|---|---|---|---|---|---|
| Male sex, No. (%) | 1321 (51.3) | 1783 (43.7) | 388 (45.6) | 249 (49.1) | <.001 |
| Age, median (IQR), y | 6.6 (3.9-10.3) | 6.7 (4.0-10.6) | 6.0 (3.8-10.0) | 6.4 (3.7-10.4) | .12 |
| Annual household income, $US, No. (%) | |||||
| 0-49 999 | 772 (30.0) | 2956 (72.6) | 598 (70.7) | 218 (43.1) | <.001 |
| 50 000-99 999 | 551 (21.4) | 172 (4.2) | 82 (9.7) | 84 (16.6) | |
| ≥100 000 | 295 (11.5) | 51 (1.3) | 9 (1.1) | 55 (10.9) | |
| Prefer not to answer | 958 (37.2) | 895 (22.0) | 157 (18.6) | 149 (29.5) | |
| Duration of AD, median (IQR), y | 4.1 (2.3-7.1) | 4.1 (2.3-7.3) | 3.5 (2.0-6.1) | 4.1 (2.3-7.5) | <.001 |
| History of asthma, No. (%) | 1326 (51.5) | 1815 (44.6) | 313 (36.8) | 217 (42.8) | <.001 |
| History of allergic rhinitis, No. (%) | 2069 (80.4) | 2691 (66.1) | 514 (60.5) | 333 (65.8) | <.001 |
| Family history of AD, No. (%) | 1458 (56.6) | 2335 (57.2) | 338 (39.7) | 301 (59.4) | <.001 |
| AD disease control in past 6 mo, No. (%) | |||||
| Complete | 183 (7.1) | 135 (3.3) | 63 (7.4) | 24 (4.8) | <.001 |
| Good | 1319 (51.2) | 1856 (45.6) | 367 (43.3) | 254 (50.3) | |
| Limited | 871 (33.8) | 1662 (40.8) | 316 (37.3) | 187 (37.0) | |
| Uncontrolled | 201 (7.8) | 419 (10.3) | 102 (12.0) | 40 (7.9) | |
| Used prescription medication and/or topical steroid for AD in past 6 mo, No. (%) | 2528 (98.3) | 3929 (96.4) | 829 (97.5) | 489 (96.5) | <.001 |
| Any health care visit for AD in past 6 mo, No. (%) | 2357 (92.0) | 3914 (96.7) | 823 (97.3) | 473 (94.6) | <.001 |
Abbreviations: AD, atopic dermatitis; IQR, interquartile range; NA, not applicable.
Includes patients of Asian, American Indian/Alaskan Native, Pacific Islander, and multiracial race/ethnicity.
Kruskal-Wallis or χ2 test, as appropriate.
Table 2. Association of Race/Ethnicity With School Absences Owing to AD.
| Race/Ethnicity | ≥6 School Days Missed in the Past 6 Months | ||
|---|---|---|---|
| Children, No./Total No. (%)a | Unadjusted OR (95% CI) | Adjusted ORb (95% CI) | |
| White non-Hispanic | 43/2299 (1.9) | 1 [Reference] | 1 [Reference] |
| Black non-Hispanic | 136/3821 (3.6) | 1.94 (1.37-2.74) | 1.49 (1.01-2.18) |
| Hispanic | 49/710 (6.9) | 3.89 (2.56-5.91) | 3.41 (2.16-5.38) |
| Otherc | 13/440 (3.0) | 1.60 (0.85-3.00) | 1.49 (0.77-2.90) |
| Female sex | NA | NA | 1.08 (0.82-1.42) |
| Age, y | NA | NA | 0.95 (0.90-0.999) |
| Household income | |||
| $0-$49 999 | NA | NA | 1 [Reference] |
| $50 000-$99 999 | NA | NA | 0.55 (0.31-0.97) |
| ≥$100 000 | NA | NA | 0.40 (0.16-1.01) |
| Prefer not to answer | NA | NA | 0.69 (0.49-0.97) |
| Duration of AD, y | NA | NA | 1.07 (1.01-1.13) |
| History of asthma | NA | NA | 1.78 (1.31-2.40) |
| History of allergic rhinitis | NA | NA | 2.03 (1.35-3.05) |
| AD disease control in past 6 mo. | |||
| Complete | NA | NA | 1 [Reference] |
| Good | NA | NA | 0.77 (0.33-1.82) |
| Limited | NA | NA | 1.94 (0.84-4.50) |
| Uncontrolled | NA | NA | 6.36 (2.71-14.89) |
| Health care visit for AD in past 6 mo | NA | NA | 2.04 (0.74-5.60) |
Abbreviations: AD, atopic dermatitis; NA, not applicable; OR, odds ratio.
Excluding 738 patients who are not enrolled in school or day care.
Adjusted for sex, age, household income, duration of atopic dermatitis, history of asthma and allergic rhinitis, recent AD disease control, and recent health care visit for AD.
Includes patients of Asian, American Indian/Alaskan Native, Pacific Islander, and multiracial race/ethnicity.
Discussion
We found non-Hispanic black and Hispanic children to be 1.5-fold and 3.4-fold more likely to have missed at least 6 days of school because of AD, respectively, compared with non-Hispanic white children after controlling for sociodemographic factors, AD control, health care visits, and atopic comorbidities. Our findings suggest racial/ethnic disparities in school absenteeism associated with AD that differ from estimates of school absenteeism by race/ethnicity in the United States which find chronic absenteeism to be highest among non-Hispanic black children (17.3%), followed by Hispanic children (14.1%) and non-Hispanic white children (12.7%).4 In contrast, we observed AD-related school absenteeism to be highest among Hispanic children followed by non-Hispanic black and non-Hispanic white children. Although the reasons for these differences require further study, one potential explanation for the observed differences is that AD may have greater negative impact on quality of life among persons belonging to racial and ethnic minority groups, as has been observed in another chronic skin disease.5 In turn, racial/ethnic differences in health-related quality of life may directly affect school attendance.6 Study limitations include self-reported data, residual unmeasured confounding, and too few outcomes in the other racial groups to draw inference. In addition, because the PEER cohort only includes children with previous topical pimecrolimus use, our findings may not be generalizable to all children with AD. Children who are chronically absent from school are more likely to fall behind or drop out.4 Understanding the factors that drive racial and ethnic differences in AD-related absences can ensure that efforts to reduce absenteeism are directed toward the most vulnerable children.
References.
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