Is there violence in the neighbourhood? Ask the children

BACKGROUND: Community violence is a major public health concern. Much has been written about high intensity community violence such as wars or gang violence. However, chronic low intensity community violence is greatly overlooked. The objective of the following study is to assess how children living in neighbourhoods characterized by chronic low intensity violence perceive their environment. METHODS: Children drew two pictures: one of their physical neighbourhoods and the other representing what goes on in the neighbourhoods. Each child also completed a neighbourhood safety survey. RESULTS: The participants were four hundred and five children (213 girls; 192 boys) 8-12 years old (mean = 9.70; SD = 1.26) who lived in Beirut. 75 drawings contained violent incidents (fist fights and heated verbal arguments were most commonly depicted). 168 children mentioned people fighting or quarrelling in the streets but elected not to draw them. Children reported feeling unsafe and dissatisfaction with the quality of their neighbourhoods. CONCLUSION: Children living in chronic low intensity community violence may feel unsafe and distrustful of their environment but may perceive violent events as regular normal occurrence. The risk of copying such behaviours and propagating violence is to be considered seriously.     

Association Between Socioeconomic Status and the Development of Asthma: Analyses of Income Trajectories

Objectives. Using data on 2868 children born in the Western Australian Pregnancy Cohort (Raine) Study, we examined the association between changes in family socioeconomic status and childhood asthma.Methods. We determined the likelihood (odds ratio) of a child having asthma at ages 6 and 14 years for 4 family-income trajectories (chronic low, increasing, decreasing, and never low) over the child''s lifetime. The trajectories were created from longitudinal latent-class models.Results. We found a 2-fold increased risk of asthma at age 14 years among children who had lived in a low-income family since birth, especially for girls. Asthma was less likely to occur in children born to single parents; income rose over time in many of these families. Compared with children in chronic low-income families, children in households with increasing incomes had a 60% lower risk of asthma. Single-point measures of low income were not found to be associated with asthma.Conclusions. Chronic exposure to a low-income environment from birth was associated with the development of persistent asthma. There was also a protective effect against asthma among those children whose families had moved out of poverty.Asthma disproportionately burdens children living in economically disadvantaged urban communities. Some of this disparity can be attributed to the observation that once asthma is established, lower utilization of prophylactic medications and higher rates of hospitalization are more common among low-income children than among high-income children.^1,2 Evidence for the link between socioeconomic status (SES) and the development of asthma is less strong—and is, in fact, contradictory.^1,3 Many studies report asthma to be more prevalent among low-SES children, even in countries with universal health care insurance.^4–7 However, no association with SES was reported in 1 study,⁸ and another study documented lower rates of asthma among low-SES children.⁹ The latter finding is congruent with the lower prevalence of atopic disease in developing countries¹⁰ and with the “hygiene” hypothesis, which proposes that exposure to infections and endotoxin is protective against atopic asthma.¹¹ Low-income children have higher infection rates, although endotoxin levels are not always elevated in low-income households.¹²Despite this level of uncertainty, it is common for household SES to be treated as a confounding factor and to be used to statistically adjust models testing the association between early life exposures and the development of childhood asthma. As low-income mothers are more likely to smoke and less likely to breastfeed,^13,14 SES acts as a proxy measure for these exposures in the absence of available data. However, there is a lack of recognition that contradictory findings on the association of SES with childhood asthma may be a function of the validity of the SES measure. Low-income variables are fraught with measurement error, and there may be considerable fluctuation in household income over the course of a child''s life from birth to adolescence.¹⁵ Measures of cumulative income, such as the frequency of low-income episodes over time, have shown stronger associations with poor health than have single-point measures.¹⁶ Other SES trajectories, such as downward or upward social mobility, have been reported to increase and decrease risk of cardiovascular disease, respectively.¹⁷ Fluctuations in family income also affect family functioning and maternal mental health.¹⁸The effects of chronic poverty on child functioning and health have long been recognized.^19,20 However, few studies have evaluated childhood asthma in relation to cumulative household income or income trajectories from the time of birth.²¹ Low-income households and neighborhoods are characterized by high levels of chronic stress,^1,22 but no longitudinal studies have investigated the relationship between chronic poverty, chronic stress, and asthma development. To fill this gap in the literature, we studied the relationship between family SES trajectories starting from birth of the child and asthma development in early school age and adolescence. We used maximum-likelihood longitudinal latent-class modeling techniques to identify SES trajectories over time.^15,23     

The association between childhood asthma prevalence and monitored air pollutants in metropolitan areas, United States, 2001-2004

Background

Air pollution exposure has been linked to adverse respiratory health outcomes among children, primarily in studies of acute exposures that are often in limited geographic areas. We sought to assess the association between chronic outdoor air pollution exposure, as measured by 12-month averages by county, and asthma among children in metropolitan areas across the nation.

Methods

Eligible children included those aged 3-17 years residing in US metropolitan areas who were sampled in the 2001-2004 National Health Interview Survey (N=34,073). 12-month average air pollutant levels for sulfur dioxide, nitrogen dioxide, ozone and particulate matter were compiled by county for 2000-2004. Eligible children were linked to pollutant levels for the previous 12 months for their county of residence. Adjusted odds ratios of having current asthma or an asthma attack in the past 12 months were estimated in single pollutant logistic regression models.

Results

Children in counties with ozone and, to a less consistent degree, particulate matter levels in the highest quartile were more likely to have current asthma and/or a recent asthma attack than children residing in counties with the lowest pollution levels; the adjusted odds for current asthma for the highest quartile of estimated ozone exposure was 1.56 (95% confidence interval [CI]: 1.15, 2.10) and for recent asthma attack 1.38 (95% CI: 0.99, 1.91). No associations were found with sulfur dioxide or nitrogen dioxide levels.

Conclusion

Although the current US standard for ozone is based on short-term exposure, this cross-sectional study suggests that chronic (12-month) exposure to ozone and particles is related to asthma outcomes among children in metropolitan areas throughout the US.     

Health, place and childhood asthma in southwest Alaska

Social science theories of health and place posit that individuals perceive a relationship between characteristics of the geographic location in which they reside and their health, well-being, and self-identity. A number of ethnographies of health and place have studied how urban and suburban populations impacted by industrial pollution or waste have come to perceive a link between rates of cancer and their unhealthy environment. There has been little study of the applicability of the health and place framework to community perceptions of long-term chronic illness. This paper examines the asthma perceptions of Yup'ik parents of asthmatic children using data from semi-structured ethnographic interviews conducted in five villages and one town of the Yukon-Kuskokwim delta of southwest Alaska. Informants cited local climatic features, large-scale changes of the last 30 years to the village built landscape, and ongoing conditions of substandard housing and sanitation as etiological factors associated with childhood asthma. Our study suggests the need for further research concerning lay perceptions of one aspect of the epidemilogic transition-the association between chronic illness and place, especially in rural communities undergoing dramatic developmental change.     

An association between fine particles and asthma emergency department visits for children in Seattle.

Asthma is the most common chronic illness of childhood and its prevalence is increasing, causing much concern for identification of risk factors such as air pollution. We previously conducted a study showing a relationship between asthma visits in all persons < 65 years of age to emergency departments (EDs) and air pollution in Seattle, Washington. In that study the most frequent zip codes of the visits were in the inner city. The Seattle-King County Department of Public Health (Seattle, WA) subsequently published a report which showed that the hospitalization rate for children in the inner city was over 600/100,000, whereas it was < 100/100,000 for children living in the suburbs. Therefore, we conducted the present study to evaluate whether asthma visits to hospital emergency departments in the inner city of Seattle were associated with outdoor air pollution levels. ED visits to six hospitals for asthma and daily air pollution data were obtained for 15 months during 1995 and 1996. The association between air pollution and childhood ED visits for asthma from the inner city area with high asthma hospitalization rates were compared with those from lower hospital utilization areas. Daily ED counts were regressed against fine particulate matter (PM), carbon monoxide (CO), sulfur dioxide, and nitrogen dioxide using a semiparametric Poisson regression model. Significant associations were found between ED visits for asthma in children and fine PM and CO. A change of 11 microg/m3 in fine PM was associated with a relative rate of 1.15 [95% confidence interval (CI), 1.08-1.23]. There was no stronger association between ED visits for asthma and air pollution in the higher hospital utilization area than in the lower utilization area. These findings were seen when estimated PM2.5 concentrations were below the newly adopted annual National Ambient Air Quality Standard of 15 microg/m3.     

The Breathe-Easy Home: the impact of asthma-friendly home construction on clinical outcomes and trigger exposure

Objectives. We examined the asthma-control benefit of moving into an asthma-friendly Breathe-Easy home (BEH).Methods. We used a quasi-experimental design to compare the asthma outcomes of 2 groups of low-income children and adolescents with asthma: 34 participants who moved into a BEH, and a local matched cohort of 68 participants who had received a previous asthma-control intervention. Both groups received in-home asthma education. BEHs were constructed with moisture-reduction features, enhanced ventilation systems, and materials that minimized dust and off-gassing.Results. BEH residents’ asthma-symptom–free days increased from a mean of 8.6 per 2 weeks in their old home to 12.4 after 1 year in the BEH. The proportion of BEH residents with an urgent asthma-related clinical visit in the previous 3 months decreased from 62% to 21%. BEH caretakers’ quality of life increased significantly. The BEH group improved more than did the comparison group, but most differences in improvements were not significant. Exposures to mold, rodents, and moisture were reduced significantly in BEHs.Conclusions. Children and adolescents with asthma who moved into an asthma-friendly home experienced large decreases in asthma morbidity and trigger exposure.Asthma remains the most common chronic condition of childhood, affecting 9.1% of all US children. More than 6 million children have current asthma, leading to 205 000 pediatric hospitalizations and 697 000 emergency department visits each year.¹ Socioeconomic and racial/ethnic disparities in asthma prevalence and morbidity continue undiminished.^2,3 Exposure and sensitization to allergens and irritants found in the indoor environment are major factors in the development and exacerbation of asthma.⁴ Low-income and racial/ethnic minority children have high levels of exposure and sensitization to indoor asthma triggers.^5–10 As much as 40% of the excess asthma risk in minority children may be attributable to exposure to residential allergens.¹¹ Disparities in asthma morbidity and allergic sensitization may be due in part to substandard housing.^7,12–14 Moisture and dampness, poor ventilation, deteriorated carpeting, and structural deficits can contribute to increased presence of indoor asthma triggers.^15,16For the past 14 years we have been studying the asthma-control effectiveness of community health worker (CHW) home visits to low-income children with asthma in Seattle and King County, Washington. In these visits, CHWs provide asthma self-management support and help participants implement multifaceted interventions that address multiple triggers. We found that such comprehensive, relatively inexpensive interventions were effective at reducing asthma morbidity and improving quality of life, and studies of other home-visit programs have found similar results.^17–21 However, many low-income children with asthma live in substandard housing that exposes them to clinically significant levels of asthma triggers. Only rarely can home visits address the structural deficiencies that lead to these exposures.A public-housing redevelopment project in Seattle offered a unique opportunity to study the health impact that moving to specially constructed asthma-friendly homes would have on children with asthma. We assessed the effect of asthma-friendly homes on asthma-symptom days, urgent health care visits, caretaker quality of life, and exposure to indoor asthma triggers among children with asthma. We hypothesized that living in an asthma-friendly home would add benefits beyond those conferred by asthma-control education and self-management support.     

宜昌夷陵地区儿童肥胖合并哮喘调查及影响因素

目的 探究宜昌市夷陵地区儿童肥胖合并哮喘患儿调查及影响因素.方法 采用分层随机整群抽样方法选取2018-2019年夷陵地区肥胖合并哮喘患儿379例,同期210例体检健康儿童作为对照组.通过问卷调查方式获取患儿一般资料,并进行单因素及多因素logistic分析.结果 肥胖伴哮喘患儿男性、居住在城市、存在哮喘家族史、二手烟...     

Variability in Asthma Care and Services for Low-Income Populations among Practice Sites in Managed Medicaid Systems

Objective. To characterize and describe variability in processes of asthma care and services tailored for low–income populations in practice sites participating in Medicaid managed care (MMC).
Study Setting. Eighty-five practice sites affiliated with five not-for-profit organizations participating in managed Medicaid (three group-model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs]).
Study Design/Data Collection. We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low-income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from "never" to "always"). We report mean and standard deviations of item scores and rankings relative to other items. We used within-MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO.
Principal Findings. Processes of care related to asthma varied greatly in how often practice sites reported doing them, with information systems and self-management support services ranking lowest. There was also significant variation in the availability of services targeting low-income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site-to-site variation was attributable to the MCO.
Conclusions. Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self-management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.     

Asthma and farm exposures in a cohort of rural Iowa children

Epidemiologic studies of farm children are of international interest because farm children are less often atopic, have less allergic disease, and often have less asthma than do nonfarm children--findings consistent with the hygiene hypothesis. We studied a cohort of rural Iowa children to determine the association between farm and other environmental risk factors with four asthma outcomes: doctor-diagnosed asthma, doctor-diagnosed asthma/medication for wheeze, current wheeze, and cough with exercise. Doctor-diagnosed asthma prevalence was 12%, but at least one of these four health outcomes was found in more than a third of the cohort. Multivariable models of the four health outcomes found independent associations between male sex (three asthma outcomes), age (three asthma outcomes), a personal history of allergies (four asthma outcomes), family history of allergic disease (two asthma outcomes), premature birth (one asthma outcome), early respiratory infection (three asthma outcomes), high-risk birth (two asthma outcomes), and farm exposure to raising swine and adding antibiotics to feed (two asthma outcomes). The high prevalence of rural childhood asthma and asthma symptoms underscores the need for asthma screening programs and improved asthma diagnosis and treatment. The high prevalence of asthma health outcomes among farm children living on farms that raise swine (44.1%, p = 0.01) and raise swine and add antibiotics to feed (55.8%, p = 0.013), despite lower rates of atopy and personal histories of allergy, suggests the need for awareness and prevention measures and more population-based studies to further assess environmental and genetic determinants of asthma among farm children.     

The impact of parental smoking on asthma and wheezing. SIDRIA Collaborative Group. Studi Italiani sui Disturbi Respiratori nell'Infanzia e l'Ambiente.

To evaluate the impact of parental smoking on childhood asthma and wheezing, we studied two random samples of subjects ages 6-7 and 13-14 years in ten areas of northern and central Italy. Standardized questionnaires were completed by parents of 18,737 children and 21,068 adolescents (response rates, 92.8% and 96.3%, respectively) about their smoking habits and the respiratory health of their children. Adolescents were asked about their respiratory health and personal smoking. We compared two groups of cases with healthy subjects: (1) "current asthma" (children, 5.2%; adolescents, 6.2%) and (2) "current wheezing" not labeled as asthma (children = 4.5%, adolescents = 8.5%). Exposure to smoke of at least one parent increased the relative risk of current asthma among children [odds ratio (OR) = 1.34; 95% confidence interval (CI) = 1.11-1.62] and of current wheezing among adolescents (OR = 1.24; 95% CI = 1.07-1.44). Maternal smoking had a stronger effect than paternal smoking. Maternal smoking during pregnancy was associated with current asthma (OR = 1.62; 95% CI = 1.34-1.96) and current wheezing in children (OR = 1.31; 95% CI = 1.06-1.62); the effects were lower among adolescents. Among subjects with a negative history of parental asthma, maternal smoking was associated with current wheezing in both age groups, whereas among those with a positive history of parental asthma it was associated with current asthma in children, but not in adolescents. We estimated that 15% (95% CI = 12-19) of the current asthma cases among children and 11% (95% CI = 8.3-14) of the current wheezing cases among adolescents are attributable to parental smoking in Italy.     

Childhood Overweight/Obesity and Pediatric Asthma: The Role of Parental Perception of Child Weight Status

Childhood obesity and asthma are on the rise in the U.S. Clinical and epidemiological data suggest a link between the two, in which overweight and obese children are at higher risk for asthma. Prevention of childhood obesity is preferred over treatment, however, in order to be receptive to messages, parents must perceive that their child is overweight. Many parents do not accurately assess their child’s weight status. Herein, the relation between parental perceptions of child weight status, observed body mass index (BMI) percentiles, and a measure of child feeding practices were explored in the context of asthma, food allergy, or both. Out of the children with asthma or food allergy that were classified as overweight/obese by BMI percentiles, 93% were not perceived as overweight/obese by the parent. Mean scores for concern about child weight were higher in children with both asthma and food allergy than either condition alone, yet there were no significant differences among the groups in terms of pressure to eat and restrictive feeding practices. In summary, parents of children with asthma or food allergy were less likely to recognize their child’s overweight/obese status and their feeding practices did not differ from those without asthma and food allergy.     

Respiratory and other health effects reported in children exposed to the World Trade Center disaster of 11 September 2001

Background

Effects of the World Trade Center (WTC) disaster on children’s respiratory health have not been definitively established.

Objective

This report describes respiratory health findings among children who were < 18 years of age on 11 September 2001 (9/11) and examine associations between disaster-related exposures and respiratory health.

Methods

Children recruited for the WTC Health Registry (WTCHR) included child residents and students (kindergarten through 12th grade) in Manhattan south of Canal Street, children who were south of Chambers Street on 9/11, and adolescent disaster-related workers or volunteers. We collected data via computer-assisted telephone interviews in 2003–2004, with interview by adult proxy for children still < 18 years of age at that time. We compared age-specific asthma prevalence with National Health Interview Survey estimates.

Results

Among 3,184 children enrolled, 28% were < 5 years of age on 9/11; 34%, 5–11 years; and 39%, 12–17 years. Forty-five percent had a report of dust cloud exposure on 9/11. Half (53%) reported at least one new or worsened respiratory symptom, and 5.7% reported new asthma diagnoses. Before 9/11, age-specific asthma prevalence in enrolled children was similar to national estimates, but prevalence at interview was elevated among enrollees < 5 years of age. Dust cloud exposure was associated with new asthma diagnosis (adjusted odds ratio = 2.3; 95% confidence interval, 1.5–3.5).

Conclusions

Asthma prevalence after 9/11 among WTCHR enrollees < 5 years of age was higher than national estimates, and new asthma diagnosis was associated with dust cloud exposure in all age groups. We will determine severity of asthma and persistence of other respiratory symptoms on follow-up surveys.     

Children's asthma experience and the importance of place

Asthma is increasing dramatically among poor, inner-city children. Fourteen children with, and twelve without, asthma were interviewed and observed to examine how children with asthma understand their illness and how the asthma experience shapes their sense of place. Quantitative data showed no difference in objective preferences for particular places, but qualitative analysis showed important differences. We identified eight place-related themes, and on seven there were clear differences between children with and without asthma--offering freedom, being aesthetically pleasing, being comfortable, nature of social contact, being isolating, being familiar and being safe. Children experienced asthma as an interruption in daily life that influences time spent outside, being active and being with friends. Children with asthma are more sensitive to places that are 'dirty' or contain asthma triggers, are less likely to explore new or people-free places and emphasize family interactions, while children without asthma emphasize friendships and are sensitive to neighborhood violence.     

Residential traffic and children's respiratory health

BACKGROUND: Living near traffic has been associated with asthma and other respiratory symptoms. Most studies, however, have been conducted in areas with high background levels of ambient air pollution, making it challenging to isolate an independent effect of traffic. Additionally, most investigations have used surrogates of exposure, and few have measured traffic pollutants directly as part of the study. OBJECTIVE: We conducted a cross-sectional study of current asthma and other respiratory symptoms in children (n = 1,080) living at varying distances from high-traffic roads in the San Francisco Bay Area, California, a highly urbanized region characterized by good regional air quality due to coastal breezes. METHODS: We obtained health information and home environmental factors by parental questionnaire. We assessed exposure with several measures of residential proximity to traffic calculated using geographic information systems, including traffic within a given radius and distance to major roads. We also measured traffic-related pollutants (nitrogen oxides and nitrogen dioxide) for a subset of households to determine how well traffic metrics correlated with measured traffic pollutants. RESULTS: Using multivariate logistic regression analyses, we found associations between current asthma and residential proximity to traffic. For several traffic metrics, children whose residences were in the highest quintile of exposure had approximately twice the adjusted odds of current asthma (i.e., asthma episode in the preceeding 12 months) compared with children whose residences were within the lowest quintile. The highest risks were among those living within 75 m of a freeway/highway. Most traffic metrics correlated moderately well with actual pollutant measurements. CONCLUSION: Our findings provide evidence that even in an area with good regional air quality, proximity to traffic is associated with adverse respiratory health effects in children.     

Why modest geographic effects for asthma? Pharmaceutical treatment as neutralizing mechanism

Research on geographic health effects has been greatly advanced with the development of multilevel statistical techniques but less is known about the possible mechanisms by which social and geographical environments may affect physical health. In spite of well-established relationships between asthma etiology and the broader living environments, multilevel research on asthma shows at best marginal geographic effects. Based on in-depth, open-ended interviews with 50 caretakers of school-age children (6-12 years) diagnosed with asthma living in two different communities, this article elucidates mechanisms by which neighborhood effects may be neutralized. Caretakers of children with mild, controllable asthma attempt to create asthma-safe zones by administering long-term control and quick-relief medication, by removing indoor environmental triggers and by avoiding dangerous environments. At home, school and outdoors, the key strategy to control asthma was the use of relatively effective and accessible medications. Children with severe asthma did not benefit as much from medications but it was unclear that different communities made a difference in asthma care.     

An attributable risk model for exposures assumed to cause both chronic disease and its exacerbations

BACKGROUND: Many chronic diseases are the product of an underlying pathologic condition and superimposed acute exacerbations. This model may apply to several conditions such as asthma, other obstructive lung diseases, or atherosclerosis. For exposures affecting both the development of chronic disease and its exacerbation, the usual methods to derive attributable risks (AR) are inappropriate. METHODS: We expand traditional risk assessment methods to estimate the AR for exacerbations under a "chronic disease model." We use asthma in children as the chronic disease and air pollution as the exposure of interest. We estimate bronchitis symptom exacerbations attributable to air pollution, using data from the Children's Health Study to estimate asthma prevalence and symptom occurrence, and we examine the distribution of exposure and its acute and chronic effects. RESULTS: In the combined AR model, 39.8% of exacerbations were attributable to air pollution, compared with 33.5% in the traditional model, which ignores a chronic effect of pollution on asthma development. Thus, there is a 1.19-fold higher estimated burden with the combined model. The difference is due to exacerbations caused by other factors (ie, not by air pollution) but nonetheless occurring among those assumed to have asthma that developed due to traffic-related pollution. The proposed model is applicable to other risk factors that play a role both in both the development of a chronic disease and its exacerbation. CONCLUSIONS: Traditional approaches to the calculation of attributable risk may underestimate the health impact of long-term environmental or other exposures that produce both chronic and acute disease.     

Acute effects of urban ambient air pollution on respiratory symptoms, asthma medication use, and doctor visits for asthma in a cohort of Australian children

We enrolled a cohort of primary school children with a history of wheeze (n=148) in an 11-month longitudinal study to examine the relationship between ambient air pollution and respiratory morbidity. We obtained daily air pollution (ozone, particulate matter less than 10 microm, and nitrogen dioxide), meteorological, and pollen data. One hundred twenty-five children remained in the final analysis. We used logistic regression models to determine associations between air pollution and respiratory symptoms, asthma medication use, and doctor visits for asthma. There were no associations between ambient ozone concentrations and respiratory symptoms, asthma medication use, and doctor visits for asthma. There was, however, an association between PM(10) concentrations and doctor visits for asthma (RR=1.11, 95% CI=1.04-1.19) and between NO(2) concentration and wet cough (RR=1.05, 95% CI=1.003-1.10) in single-pollutant models. The associations remained significant in multipollutant models. There was no consistent evidence that children with wheeze, positive histamine challenge, and doctor diagnosis of asthma reacted differently to air pollution from children with wheeze and doctor diagnosis of asthma and children with wheeze only. There were significant associations between PM(10) levels and doctor visits for asthma and an association between NO(2) levels and the prevalence of wet cough. We were, however, unable to demonstrate that current levels of ambient air pollution in western Sydney have a coherent range of adverse health effects on children with a history of wheezing.