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JOURNAL OF ASTHMA Vol. 41, No. 2, pp. 147–157, 2004

ORIGINAL ARTICLE

Latino Children with Asthma: Rates and Risks for Medical Care Utilization Jill Berg, Ph.D.,1 Dennis R. Wahlgren, M.A.,2 C. Richard Hofstetter, Ph.D.,2,3 Susan B. Meltzer, M.P.H.,2 Eli O. Meltzer, M.D.,5 Georg E. Matt, Ph.D.,4 Ana Martinez-Donate, Ph.D.,2 and Melbourne F. Hovell, Ph.D., M.P.H.2,* 1

UCLA School of Nursing, Los Angeles, California, USA Center for Behavioral Epidemiology and Community Health (C-BEACH), Graduate School of Public Health, 3Department of Political Science, College of Arts and Letters, and 4Department of Psychology, College of Sciences, San Diego State University, San Diego, California, USA 5 Allergy and Asthma Medical Group and Research Center, San Diego, California, USA

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ABSTRACT Latino families have been reported to underutilize health care services compared with families from other ethnic backgrounds. As part of a community trial in a low income Latino population designed to decrease environmental tobacco smoke (ETS) exposure in children with asthma in San Diego, we examined unscheduled medical care for asthma. Latino families (N = 193) reported information about medical care use for their children during the past 12 months. About 23% were hospitalized, 45% used the emergency department, and 60% used urgent care services. About 8.5% of families had two or more hospitalizations in 12 months. Most families were insured by Medicaid or had no insurance. Significant risk factors for a child’s hospitalization were age (under age six), failure to use a controller medication, and a parental report of the child’s health status as being poor. Risk factors for emergency department use were age (under age six) and male gender. These findings indicate that low-income Latino families with young children with asthma lack the medical resources necessary for good asthma control. Quality and monitored health care with optimization of asthma management could reduce costly acute care services. Key Words: Environmental tobacco smoke (ETS); Passive smoke exposure; Childhood asthma; Medical care; Medically-underserved; Latino asthma.

*Correspondence: Dr. Melbourne Hovell, Center for Behavioral Epidemiology and Community Health, Graduate School of Public Health (C-BEACH), 9245 Sky Park Court, Suite 230, San Diego, CA 92123, USA; E-mail: [email protected]. 147 DOI: 10.1081/JAS-120026072 Copyright D 2004 by Marcel Dekker, Inc.

0277-0903 (Print); 1532-4303 (Online) www.dekker.com

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INTRODUCTION

METHODS

Asthma is a chronic illness that requires knowledgeable medical management with periodic monitoring (1). Prevalence of asthma is greater among certain racial and ethnic inner city pediatric populations living in poverty. These children also have worse asthma outcomes than other children living in the United States (2). Control of asthma among low-income families is dependent to a considerable degree on access to medical care. This is specifically a concern in the rapidly increasing low-income Latino population of California where there is a growing need for services, especially asthma care. There are presently 35 million Latinos living in the United States. This fast-growing minority group is predicted to increase to 98 million by the year 2050 (3). According to the most recent census, Latinos are often young, poorly educated, and hold low-paying, labor and service jobs. The census revealed that the largest subgroup of Latinos are of Mexican descent and constitute 58.4% of the total Latino population in the U.S. (4). Researchers have studied the barriers to health care use in Latino families (5,6). Earlier studies identified barriers that related to culture and language differences. More recent findings indicate that characteristics of the health system and lack of health insurance are the key barriers to quality of care. Compared to other nationalities, Mexican families are more often uninsured and least likely to seek health care for preventive as well as chronic health problems (7,8). Latino children with asthma in California on Medicaid are hospitalized approximately twice as frequently for an asthma episode as their private-pay counterparts (9). This appears to be due to inadequate routine asthma care and also to the substandard followup care after hospital discharge. Although hospital care may be the same for those with and without health insurance, post-discharge care for the uninsured may not be available. Latino children on Medicaid are also more likely to be discharged without prescriptions for inhaled steroid medications, a fact that may partially explain the subsequent less than optimal asthma control (9,10). This paper describes medical care utilization patterns reported by San Diego families of Mexican origin who have a child with asthma. Variables associated with unscheduled medical visits are examined. The data underscore the need to improve medical care for disadvantaged Latino children with asthma.

Data Source and Study Population This report is an assessment of medical care use among San Diego, California Latino families with a child with asthma. San Diego is situated on the border adjacent to Tijuana, Mexico. Data were collected from the baseline measurements from participants of a community trial designed to test parental coaching to reduce environmental tobacco smoke (ETS) exposure among children with asthma (11). Families were recruited through several community sources targeting low-income Latino families, including Spanish-language newspapers, neighborhood health fairs, school nurses, community medical clinics, and sites for the Women, Infants, and Children (WIC) supplemental nutrition program and the Head-Start program. From the 204 Latino families recruited into the study, 193 completed measures for the primary trial outcomes and the present analyses. This study was approved by the San Diego State University (SDSU), University of California, San Diego (UCSD), and Mercy Hospital committees for protection of human subjects participating in research. Inclusion/Exclusion Criteria Eligibility criteria included 1) a self-identified Latino mother or father, 2) a child 3 –17 years of age, with either a physician diagnosis of asthma or a prescription for bronchodilator medication for ‘‘breathing problems,’’ 3) an exposure to at least six cigarettes in the past seven days, and 4) an adult smoker living in the home. Among the adult caretaker respondents, 98% were the mothers of the child with asthma. Table 1 lists the descriptive characteristics of the families that participated in the trial. Measures Bilingual/bicultural project staff collected all data. Interviews were conducted in the subject’s home, at a time convenient to the identified caretaker, and questions directed primarily toward the caregiver. All eligible families had a home assessment screening at baseline. The home assessment screening contained questions about the home environment, including number of rooms in the house, number of occupants, pets, use of gas stoves, type of heaters, etc. The presence of carpeting, air conditioners, plants, stuffed animals, and other asthma triggers, as well as asthma

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Medical Services for Latino Children with Asthma Table 1.

Study participants (n = 193).

Characteristic Child’s age 6 years or younger Older than 6 years Child’s gender Male Caretaker’s acculturation status Hispanic Non-Hispanic Bicultural Caretaker’s education Less than high-schoola Completed high-schoola Caretaker’s immigrant status Immigrant First generation Caretaker’s language preference Spanish Child’s NIH severity rating Intermittent Mild persistent Moderate persistent Severe persistent Child’s home environment (not mutually exclusive) Bedroom triggers Bedroom controllers Pets Share room with smoker Health care use for respiratory illness past 12 months (not mutually exclusive) Hospitalizations ER visit Urgent care visit

% of participants 52.8 47.2 59.6 59.1 8.8 30.6 60.1 39.9

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urgent care facility for a ‘‘respiratory illness’’ during the past 12 months. Although for this paper we concentrated on baseline measures, we also included in our analyses information obtained from a retrospective home observation checklist. Following each family’s final interview (month 13 of participation), staff members who entered the homes also completed a retrospective checklist that assessed conditions that could affect the child with asthma. Items included condition of the carpet, presence of mice, rats, cockroaches, strong odors, and general cleanliness throughout the course of study participation. Data Analysis

69.9 13.5 83.4 9.3 44.0 30.6 16.1

99.5 39.4 13.5 32.0

23.0 43.5 57.5

a

High-school graduate or equivalent. Allows for schooling obtained in any country.

‘‘controllers’’ such as plastic mattress and pillow encasements were assessed by visual inspection during a ‘‘walk-through’’ by the interviewer. Information was also obtained by caregiver interview about the presence of other people with asthma in the household, medical care sought in the U.S. and Mexico during the past year, and barriers to medical care. The baseline interview included questions about the parents’ smoking behavior, the child’s ETS exposure level, asthma severity and treatment, and medical resource utilization. Specifically, the caretaker respondents were asked to report on the number of times the child was hospitalized, visited an emergency department, or visited an

Baseline dependent variables reflecting medical care use in the past 12 months were positively skewed and were therefore dichotomized to reflect whether or not the child had obtained each type of service at all in the past 12 months. Individual categories included hospitalization and outpatient visits to an emergency department or urgent care center. A composite category, ‘‘any use,’’ was created if any one or more of these individual services was accessed for a respiratory illness vs. none. Independent variables included sociodemographics, environmental characteristics, and asthma disease severity. Independent variables were loosely based on the Aday and Andersen Access Framework (12) and taken from other studies linking use of medical services with mother’s educational level, insurance status, increased exposure to environmental triggers, and child’s age. In order to identify correlates of medical care use, bivariate associations with the independent variables were tested by computing chi-squares with each of the medical care use categories (hospital, ER, and urgent care visits, any use). To reduce the independent variables to a parsimonious subset, variables that were associated with medical care use in bivariate analyses were retained for inclusion in subsequent multivariable analyses. Given the exploratory nature of these analyses in this population, significant (p 6 years Gender Boys Girls Parent educational level < High school High school or greater Insurance None Medi-Cal Private Acculturation Hispanic Bicultural Non-Hispanic NIH Severity 1 (Intermittent) 2 (Mild persistent) 3 (Moderate persistent) 4 (Severe persistent) Parent-reported Health Statusc Poor Fair Good Excellent Have controller meds No Yes Bedroom triggersd 0–1 2–3 4–5 Overall model fit a

9.3% had intermittent disease, 44% had mild persistent disease, 30.6% had moderate persistent disease, and 16.1% had severe persistent disease. Forty-four percent of the children lived in households with other people with asthma. When asked at baseline, few parents reported that their children used controller medications: 78.8% did not use any, 17.6% used one, and 3.6% used two. When asked to rank their child’s health status over a range of excellent, good, fair, and poor, 58% of the parents chose a rating of poor or fair. The

Nb

Hospitalizations OR (95% CI):

Emergency department use OR (95% CI)

Urgent care use OR (95% CI)

93 82

2.2 (1.0 – 4.9) referent

3.4 (1.6 – 7.1)e

1.8 (0.9 – 3.4)

102 73

1.3 (0.6 – 3.1) referent

3.0 (1.4 – 6.4)e

1.0 (0.5 – 2.0)

109 66

referent 1.7 (0.7 – 3.8)

2.2 (1.1 – 4.7)e

1.6 (0.8 – 3.3)

60 102 13

1.4 (0.2 – 8.9) 1.0 (0.2 – 6.1) referent

0.7 (0.2 – 3.3) 1.1 (0.2 – 4.5)

0.5 (0.1 – 2.4) 0.5 (0.1 – 2.2)

107 53 15

referent 1.3 (0.6 – 3.2) 1.0 (0.2 – 4.9)

1.2 (0.5 – 2.6) 3.1 (0.8 – 12.8)

1.3 (0.6 – 2.8) 1.8 (0.5 – 7.1)

14 82 53 26

referent 0.6 (0.1 – 2.7) 0.7 (0.1 – 3.2) 2.5 (0.5 – 12.9)

0.2 (0.0 – 0.7)e 0.1 (0.0 – 0.6)e 0.7 (0.1 – 3.4)

0.7 (0.2 – 2.6) 0.8 (0.2 – 2.8) 0.8 (0.2 – 3.4)

13 90 56 16

0.4 (0.2 – 0.8)e

0.6 (0.4 – 1.0)

0.9 (0.6 – 1.3)

138 37

0.4 (0.2 – 1.1) referent 0.9 (0.6 – 1.5)

1.2 (0.5 – 2.9)

0.9 (0.4 – 2.0)

1.2 (0.8 – 1.8)

1.3 (0.9 – 2.0)

w2(13) = 25.0e

w2(13) = 43.5e

w2(13) = 10.9

9 142 24

Same set of variables tested for all three models. Results reported for n = 175 participants who provided data on all included variables. c General health status was treated as a continuous variable (higher value = better health), thus producing one odds ratio. d Number of triggers was treated as a continuous variable, thus producing one odds ratio. e = p < 0.05. b

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following activities were reported as difficult for the child: household chores (30%), schoolwork (18.4%), and walking and climbing stairs (54.9%). General fatigue (48.7%) also prevented many children from engaging in routine activities. Only 3.4% of the children received allergy immunotherapy. None used a peak flow meter. Home Environment Table 1 summarizes information about the home environments. At baseline, 32% of the children shared a sleeping room with a smoker. Other environmental triggers found in the child’s sleeping area included carpeting (96.4%), drapes (49.7%), and stuffed animals (81.9%). Seventy-three percent of the families used a gas stove. Fourteen percent of the families had pets present in the house. Few families reported devices to protect children with asthma from allergens, such as plastic mattress covers (9.8%), covered air vents (10.4%), or air purifiers (3.6%). Medical Care Use Twenty-three percent of the children required a hospitalization for a respiratory illness within the 12 months prior to the study, and approximately 8.5% had more than one respiratory illness hospitalization within the 12 months. About 45% were seen in an emergency department, and 60% used urgent care facilities during this same time period. Of the 193 families, 74% reported at least one of these unscheduled services. Few families paid medical bills with private insurance (8%). The majority (55%) used Medicaid (‘‘Medi-

Figure 1.

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Cal’’) or had no insurance (32%). At baseline, 48% of the families reported that their child had a respiratory illness within the last 2 weeks. Approximately half of these families sought care for this illness, and most (92%) sought this care in the U.S. rather than Mexico. Reasons for not taking a child for medical treatment were reported as lack of resources (financial, child care, transportation, insurance) and difficulty scheduling an appointment. Factors Associated with Use of Unscheduled Medical Services The bivariate screening of independent variables resulted in several significant or near significant associations with unscheduled health care service use. Hospitalization was related to age less than six years, poorer general health status of the child, and greater NIH severity rating. Emergency department visits were associated with child’s age less than six years, male gender, a high school education or above for the caregiver, and with intermittent and severe persistent levels of asthma severity. Urgent care use was more likely for younger children, and for those whose caregiver had at least a high school education. The use of any service was similarly related to child’s age and parent’s education, and also to acculturation status (94% of non-Hispanic, 82% of bicultural, and 67% of Hispanic caretakers used any service). All variables identified above were combined with theoretically important variables (e.g., insurance status, use of controller medication) to create a single set of predictors to test in multiple logistic regressions on each health care use outcome. The set of predictors consisted

Percent who were hospitalized for respiratory illness in the previous 12 months, by selected predictors.

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Figure 2.

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Percent who used an emergency department for respiratory illness in the previous 12 months, by selected predictors.

of: child’s age, gender, general health status, NIH asthma severity rating, presence of triggers in the bedroom, use of controller medications, parent education, acculturation level, and insurance status. Multivariable odds ratios for factors associated with the specific forms of health care use are reported in Table 2. Rates of use for each service are shown in Figs. 1– 3 for a subset of predictors found significant in one or more models. Few predictors met statistical significance, but several associations were consistent in direction across the individual health care services. Focusing on these individual services, the strongest predictor of use,

controlling for all other variables in each model simultaneously, was a child under six years of age, with 1.8 to 3.4 times the risk of use for services compared to children over six. Hospital use was also more likely for children with worse general health status. Emergency department use was three times more likely for boys than girls, and over twice as likely for children of parents who had completed a high school education. Children rated as intermittent and severe persistent steps on the NIH severity scale were more likely to use the emergency department than those in the intervening steps. This U-shaped distribution (Fig. 2) is

Figure 3. Percent who used an urgent care facility for respiratory illness in the previous 12 months, by selected predictors.

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in contrast to the J-shaped distribution seen for hospital use (Fig. 1). Use of urgent care was not substantively predicted. Overall model fit was statistically significant for hospitalization [w2(13) =25.0, p= 0.023], emergency department use [w2(13) = 43.5, p< 0.001], and use of any of the three services [w2(13) = 22.8, p =0.045].

DISCUSSION These findings indicate that for this exclusively Latino low-income sample from San Diego, hospitalization, emergency, and urgent care services for children with asthma were most likely for male children, children younger than six years of age whose mothers reported the child as having worse general health, and children whose mothers had completed a high school education. These results are similar to those of other studies that examined the use of unscheduled asthma care (1,14,15), with the exception of caregiver’s education. The present data indicate that caregivers with at least a high school education or equivalent are about 1.5 to 2 times more likely to have used these services. Recent studies show some conflicting results. Meurer et al. (1) found that emergency department use was greater among parents that lacked a high school diploma. In contrast, Lieu et al. (16) did not find an association between use of services and parent education. Although other studies have documented that low income minority families in their samples were poorly educated, the link to source of care has not been consistently established. Weinick and Krauss (17) reported that children of mothers with a higher education were more likely to have a usual source of care. In the present sample, lower education was associated with less use of services, which may reflect physical barriers (i.e., limited resources) that preclude seeking medical care. Since many of these families lack the resources for access to the medical delivery system, such as finances for transportation and the flexibility to leave work for medical appointments, sources of support to overcome these kinds of economic barriers should be developed. These are critical in establishing the conditions likely to be minimally necessary for lowincome Latino families to obtain routine medical care for their children with asthma. Further, limited education and income may interact with less acculturation. Among Latinos, there is a known, culturally based aversion to seeking routine care without the ability to pay, which may be a source of substantial embarrassment to parents. The impact of parent education, in-

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come, and acculturation on usual source of asthma care should be reexamined in future studies. A surprising finding of the current study was that lack of controller medications was not a consistent predictor of unscheduled asthma medical care. Lack of controller medications was not related to service use in bivariate analyses, but its converse, having controller medications, significantly predicted hospitalization in the multivariable analysis. Previous research has linked hospitalization and the use of emergency department services to poor asthma control, especially the lack of use of asthma control medications. Merrick and colleagues (9), for example, reported that posthospital care for asthma often differed for those privately insured vs. those insured by Medicaid. One of the major differences noted was the use of a controller treatment such as inhaled steroids for those who had private insurance. Thus, the limited prescription or use of controller medications has previously been demonstrated to be a key predisposing factor for high rates of unscheduled service use by asthma patients. In contrast, among this exclusively Latino sample, hospitalization was slightly more likely among those who used controller medications (30%) compared with those who did not (21%). One possible explanation is due to the way the independent and dependent variables were measured. The questions about utilization of care asked if the service was used in the past 12 months, but presence of medications were reported at the time of the interview. It may be that those who were hospitalized received medications to take home upon discharge, and which they reported at the time of the interview. In any event, few (21%) families reported the use of controller medications, which is consistent with the findings of other studies (15,16,18). Many families reported living in substandard housing with many asthma triggers present. Although it is recognized that indoor and outdoor environmental allergens can exacerbate asthma symptoms, especially in young children, these families lack resources to substantially modify their environment. Children in our sample often slept in rooms with old carpeting, and few had any environmental controls such as mattress covers, air purifiers, etc. Few low-income, minority families have the option of moving, replacing carpeting, or buying equipment without public assistance. In addition, few of the families engaged in any preventive care or had an asthma management plan (including peak-flow monitoring) to cope with considerable environmental allergens. While these findings are not surprising in light of other studies of minority

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populations with asthma, they underscore the need for more proactive and consistent asthma education and medical treatment. However, in the absence of sufficient resources, it is not possible to obtain even the most basic environmental controllers and medical care including the critically important controller medications. Given the use of Medi-Cal by more than half of the families, this system of care could develop an organized intervention strategy that involves caregivers and their children with asthma in an educational program that specifically discusses environmental triggers, and suggest inexpensive methods of reducing these triggers. For example, while the addition of various environmental controls such as mattress covers and air purifiers may not be feasible without financial assistance, removal of stuffed toys, more frequent washings of bed linens, and similar noncostly activities are possible. Because asthma care among this population is episodic and patients lack a consistent primary care provider, asthma action plans, anti-inflammatory medications, and spacer devices are often not prescribed (1,19). The lack of medical access, knowledge about asthma, and appropriate medications almost certainly could be improved with good office-based primary medical care, but this is not likely to be achieved without the fundamental resources to get to a physician’s office during school and daytime work hours. Quality and consistent medical care would help to decrease asthma morbidity in these children. Explanations about how asthma triggers work, what they are, and ways of reducing them in and around the home environment could reduce the severity and frequency of asthma attacks among this low income, medically under-served Latino population. Forty-eight percent of the children in our sample had respiratory illnesses within the last two weeks, yet only one-half of these families sought care for the illness. Respiratory illnesses can exacerbate asthma symptoms, which if left untreated, can progress to a degree that requires emergency care. In turn, this increases frequency and duration of hospitalization, costs, and emotional burdens on the family. Clearly, more and better education about respiratory illnesses, as well as general understandings about asthma, is necessary among this population. Information about respiratory illness can also be provided through interventions either connected to Medi-Cal benefits or through doctor office visits. In the absence of a medical care system that includes subsidies for time off from employment, transportation, child care, and other basic support needed in order to take a child to a physician’s office, it may be critical to develop alternative systems where

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the medical services can be delivered to the family. Publicly supported home health nursing services and related models might offset the need for primary physician care for the family with a child with asthma. The use of a home visit is not innovative, and certain populations of patients continue to be the recipients of this type of health care. Usually home visits are targeted towards the home-bound elderly, the newly discharged surgical patient, or the new mother and infant. Most of the studies that evaluate home visits as a means of decreasing hospital readmissions and other complications in targeted groups cite success (20 – 22). In asthma, the use of a home visit has been particularly geared to evaluating indoor allergen triggers in intervention studies but not for the delivery of health care (23 – 25). Now may be the time to implement home health care for low income, minority children with asthma. This system could reduce the barriers of access to care, transportation expenses, time away from work expenses, as well as improve the availability of education about asthma and therapeutic interventions. Other types of innovative health care delivery systems have been examined for asthma care. Schoolbased clinics, and mobile asthma vans in Los Angeles, Maryland, and Arizona have recently been used to expand health services for those children with asthma who have difficulty accessing traditional health care modalities (26 – 28). Preliminary data suggest that this too, is a promising health care delivery system. Obviously, there is widespread recognition that ‘‘usual’’ office and clinic-based asthma care does not reach some very needy populations. This study did not find significance for certain variables that have traditionally been documented in the literature to ‘‘strongly’’ predict high use of unscheduled medical care. These variables include parental education (less than high school), lack of controller medication, another person with asthma living in the home, acculturation, Spanish as the primary language, and immigration status. Other variables such as environmental triggers and home conditions that would be expected to contribute to the requirements for medical care use in this sample also were not associated with higher use of unscheduled visits. One possible explanation for these findings differing from those of previous studies is that families in the current study were recent immigrants who were reluctant to use medical services in the U.S. One would expect that for U.S. citizens, health care use would be more often sought. Additionally, as income improves, one would also expect that patients with asthma would be able to afford more proactive medical care, as well as afford to change environmental conditions that trigger asthma attacks.

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An additional feature of this study was that this group of San Diego families with a child with asthma also all had ETS exposure. Environmental tobacco smoke exposure does not occur in all Latino families. Therefore, this sample is not fully representative of the population of Latino children with asthma. Exposure to tobacco smoke, however, is a major international concern (29), and the child with asthma is at higher risk for ill effects from ETS (30). It is clear that the families participating in this study had more limited resources than many other Latino families and consequently had more obstacles for obtaining medical care for their children. That these families volunteered to participate in the study suggests that they were highly motivated to provide better asthma care for their children. Based on reports from other studies (31), high-risk children with asthma who are exposed to environmental tobacco smoke need more aggressive care, given that ETS is a known irritant. Extending this reasoning, children from low-income Latino families living with a smoker should receive comprehensive asthma management education (23) and formal control of triggers, including ETS exposure (11). Families with these combined risk conditions might warrant home health nursing services in order to obtain the needed primary care services and to reduce extraordinary risks, such as exposure to ETS (11,30,32 – 36).

CONCLUSION Low-income San Diego Latino families with a child with asthma almost exclusively use unscheduled medical care for respiratory illness. Lack of health insurance, lack of a consistent health care provider, limited environmental controls of asthma triggering allergens and irritants, and infrequent prescriptions of anti-inflammatory controller medications lead to poor asthma management, worsening health status, and high use of emergency services for asthma. Latino families need to be targeted for alternative health care delivery services that provide continuity of care and use of preventive medications. Comprehensive asthma management programs have shown to be effective in reducing medical costs of emergency care and improving health outcomes in low-income populations (37,38). It is now time to widely disseminate these programs and offer them in communities and schools for all high-risk families with children with asthma. Given the resource limitations for these families that preclude their ability to attend primary care services, new or revised models of health care (including home, school, and community) should be considered as alternatives to current systems

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of care for those who cannot receive adequate and ongoing primary medical care.

ACKNOWLEDGMENTS This research was supported by Grant # HL52835 awarded to Dr. Hovell from the National Heart, Lung, and Blood Institute, NIH, and by discretionary funds from the Center for Behavioral Epidemiology and Community Health.

REFERENCES 1.

Meurer JR, George V, Subichin SJ, Malloy M, Gehring L, Milwaukee childhood asthma project team. Risk factors for pediatric asthma emergency visits. J Asthma 2000; 37(8):653 – 659. 2. Mansour ME, Lanphear BP, Dewitt TG. Barriers to asthma care in urban children: parent perspectives. Pediatrics 2000; 106(3):512– 519. 3. National Population Projections, Detailed Files: Total Population by Age, Sex, Race, Hispanic Origin, and Nativity. Available online: http:// www.census.gov/population/projections/nation/detail/d2041_50.pdf. Accessed July 3, 2002. 4. Therrien M, Ramirez RR. The Hispanic Population in the United States: March 2000, Current Population Reports, P20-535. Washington, DC: U.S. Census Bureau, 2000. 5. Guendelman S, Wagner TH. Health services utilization among Latinos and White Non-Latinos: results from a national survey. J Health Care Poor Underserved 2000; 11(2):179 –194. 6. Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to care, and use of preventative services by hispanics: findings by HHANES, 1982– 84. Am J Public Health 1990; 80(suppl):11 –19. 7. Angel RJ, Angel JL. Physical comorbidity and medical care use in children with emotional problems. Public Health Reports 1996; 111(2):140– 145. 8. Estrada AL, Trevino FM, Ray LA. Health care utilization barriers among Mexican Americans: evidence from HHANES 1982– 84. Am J Public Health 1990; 80(suppl):27 – 31. 9. Merrick NJ, Houchens R, Tillisch S, Berlow B, Landon CJ. Quality of hospital care of children with asthma: medicaid versus privately insured patients. J Health Care Poor Underserved 2001; 12(2):192– 207. 10. Finkelstein JA, Brow RW, Schneider LC. Quality

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of care for preschool children with asthma: the role of social factors and practice setting. Pediatrics 1995; 95:389– 394. 11. Hovell MF, Meltzer SB, Wahlgren DR, Matt GE, Hofstetter CR, Jones JA, Meltzer EO, Bernert JT, Pirkle JL. Asthma management and environmental tobacco smoke exposure reduction in Latino children: a controlled trial. Pediatrics 2002; 110:946 – 956. 12. Aday LA, Andersen RA. A framework for the study of access to medical care. Health Serv Res 1974; 9(3):208 –220. 13. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 97-4051. Bethesda, MD: National Heart, Lung, and Blood Institute-National Asthma Education and Prevention Program, 1997. 14. Halfon N, Newacheck PW. Childhood asthma and poverty: differential impacts and utilization of health services. Pediatrics 1993; 91(1):56 –61. 15. Wasilewski Y, Clark NM, Evans D, Levison MJ, Levin B, Mellins RB. Factors associated with emergency department visits by children with asthma: implications for health education. Am J Public Health 1996; 86:1410– 1415. 16. Lieu TA, Lozano P, Finkelstein JA, Chi FW, Jensvold NG, Capra AM, Quesenberry CP, Selby JV, Farber HJ. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics 2002; 109(5): 857– 865. 17. Weinick RM, Krauss NA. Racial/ethnic differences in children’s access to care. Am J Public Health 2000; 90(11):1771 –1774. 18. Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among medicaid-insured children with asthma. Arch Pediatr Adolesc Med 2002; 156(6):562 – 567. 19. Farber HJ, Johnson C, Beckerman RC. Young inner-city children visiting the emergency room (ER) for asthma: risk factors and chronic care behaviors. J Asthma 2001; 35(7):547 –552. 20. Restrepo A, Davitt C, Thompson S. House calls: is there an APN in the house? J Am Acad Pract 2001; 13(12):560– 564. 21. Blue L, Lang E, McMurray JJV, Davie AP, McDonagh TA, Murdoch DR, Petrie MC, Connolly E, Norrie J, Round CE, Ford I, Morrison CE. Randomized controlled trial of specialist nurse intervention in heart failure. British J Med 2001; 323:715– 718. 22. Koniak-Griffin D, Anderson NL, Brecht ML,

Berg et al.

23.

24.

25.

26.

27.

28.

29.

30.

31. 32.

33.

Verzemnieks I, Lesser J, Kim S. Public health nursing care for the adolescent mother: impact on infant health and selected maternal outcomes at 1 year postbirth. J Adolesc Health 2002; 30(1):44 – 54. Jones JA, Wahlgren DR, Meltzer SB, Meltzer EO, Hovell MF. Increasing asthma knowledge and changing home environments for Latino families with asthmatic children. Patient Educ Couns 2001; 42:67– 79. Carter MC, Perzanowski MS, Raymond A, PlattsMills TA. Home intervention in the treatment of asthma among inner-city children. J Allergy and Clin Immunol 2001; 108(5):685 – 687. Krieger JK. The seattle-king county healthy homes project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environ Health Perspect 2002; 110(suppl 2):311 –322. Jones CA, Hanley-Lopez J, Kwong KY, Clement LT, Stotts CL, Maalouf NB, Morphew TL, Chan LS, Opas LM, Lifson FJ. Breathmobilek Program: Two Year Outcomes. John Hopkins Asthma Allergy News Arch 2000. Available online: http:// www.hopkins-allergy.org/news/articles/2000/ aaaai/aaaai2000_abstract27.html. Accessed August 5, 2002. Bland K. Breathmobile Visit ‘Worth Trip’ for Mom. The Arizona Republic. Mar. 4, 2001. Available online: http://www.azcentral.com/health/ asthma/ 0304asthma04.html. Accessed August 5, 2002. Vernick S. Johns Hopkins Unveils Newest Weapon in Fight Against Asthma: The Breathmobile. Johns Hopkins Children’s Center News. August 7 2000. Available online: http://www.hopkinschil drens.org/pages/news/archivedetails.cfm?new sid = 96. Accessed August 5, 2002. World Health Organization. Air Quality Guidelines for Europe. 2nd ed. WHO Regional Publications, European Series, No. 91, Copenhagen, Denmark: World Health Organization, 2000. Wahlgren DR, Hovell MF, Meltzer EO, Meltzer SB. Involuntary smoking and asthma. Curr Opin Pulm Med 2000; 6(1):31 – 36. Institute of Medicine. Clearing the Air. Washington, DC: National Academy Press, 2000. Hovell MF, Zakarian JM, Wahlgren DR, Matt GE. Reducing children’s exposure to environmental tobacco smoke: the empirical evidence and directions for future research. Tobacco Control 2000; 9(suppl 2):ii40 –ii47. Hovell MF, Wahlgren DR, Zakarian JM, Matt GE.

ORDER

REPRINTS

Medical Services for Latino Children with Asthma

34.

35.

Reducing children’s exposure to environmental tobacco smoke: a review and recommendations. In: Watson RR, Witten M, eds.; Environmental Tobacco Smoke. Boca Raton: CRC Press, 2001. Hovell MF, Meltzer SB, Zakarian JM, Wahlgren DR, Emerson JA, Hofstetter CR, Leaderer BP, Meltzer EO, Zeiger RS, O’Connor RD, Mulvihill MM, Atkins CJ. Reduction of environmental tobacco smoke exposure among asthmatic children: a controlled trial. Chest 1994; 106:440 – 446 published erratum appears in Chest 1995, 107, 1480. Wahlgren DR, Hovell MF, Meltzer SB, Hofstetter CR, Zakarian JM. Reduction of environmental tobacco smoke exposure in asthmatic children: a 2year follow-up. Chest 1997; 111:81 – 88.

157

36.

37.

38.

Hovell MF, Zakarian JM, Matt GE, Hofstetter CR, Bernert JT, Pirkle J. Effect of counselling mothers on their children’s exposure to environmental tobacco smoke: randomised controlled trial. Br Med J 2000; 321:337 –342. Kelly CS, Morrow AL, Shults J, Nakas N, Strope GL, Adelman RD. Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in Medicaid. Pediatrics 2000; 105(5):1029– 1035. Harish Z, Bregante AC, Morgan C, Fann CSJ, Callaghan CM, Witt MA, Levinson KA, Caspe WB. A comprehensive inner-city asthma program reduces hospital and emergency room utilization. Ann Allergy, Asthma Immun 2001; 86:185 – 189.

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