The Journal of Allergy and Clinical Immunology
Volume 120, Issue 5 , Pages 1160-1165, November 2007

Parental language and asthma among urban Hispanic children

  • Giselle S. Mosnaim, MD, MS

      Affiliations

    • Department of Immunology and Microbiology, Rush Medical College, Chicago, Ill
    • Corresponding Author InformationReprint requests: Giselle Mosnaim, MD, MS, Department of Immunology and Microbiology, Rush Medical College, 1725 West Harrison, Suite 117, Chicago, IL 60612.
    • ,
  • Laura S. Sadowski, MD, MPH

      Affiliations

    • Collaborative Research Unit, Department of Medicine, Cook County Bureau of Health Services and Rush Medical College, Chicago, Ill
    • ,
  • Ramon A. Durazo-Arvizu, PhD

      Affiliations

    • Department of Preventive Medicine and Epidemiology, Loyola University Stritch School of Medicine, Chicago, Ill
    • ,
  • Lisa K. Sharp, PhD

      Affiliations

    • Department of Medicine, Section of Health Promotion Research, University of Illinois at Chicago, Chicago, Ill
    • ,
  • Laura M. Curtis, MS

      Affiliations

    • Institute for Healthcare Studies, Northwestern University, Chicago, Ill
    • ,
  • Madeleine U. Shalowitz, MD, MBA

      Affiliations

    • Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Chicago, Ill
    • ,
  • John J. Shannon, MD

      Affiliations

    • Divisions of Pulmonary and Critical Care Medicine, Stroger Hospital of Cook County, Chicago, Ill
    • ,
  • Kevin B. Weiss, MD

      Affiliations

    • Institute for Healthcare Studies, Northwestern University, Chicago, Ill

Received 2 October 2006; received in revised form 22 August 2007; accepted 22 August 2007.

Article Outline

Background

Many Hispanics in the United States have limited English proficiency and prefer communicating in Spanish. Language barriers are known to adversely affect health care quality and outcomes.

Objective

We explored the relationship between parent language preference in a Hispanic population and the likelihood that a child with symptoms receives a diagnosis of asthma.

Methods

We conducted a school-based survey in 105 Chicago public and Catholic schools. Our sample included 14,177 Hispanic children 6 to 12 years of age with a parent who completed an asthma survey. Outcomes of diagnosed asthma and possible asthma (asthma symptoms without diagnosis) were assessed by using the Brief Pediatric Asthma Screen Plus instrument.

Results

Overall, 12.0% of children had diagnosed asthma, and 12.7% had possible asthma. Parents of children at risk who completed the survey in English reported higher rates of asthma diagnosis compared with parents who completed it in Spanish (55.2% vs 36.3%, P < .001). Predictors of asthma diagnosis were child sex, parental language preference, parental asthma status, and other household members with asthma.

Conclusions

Parental language preference might be an important characteristic associated with childhood asthma diagnosis. Whether language itself is the key factor or the fact that language is a surrogate for other attributes of acculturation needs to be explored.

Clinical implications

Our findings suggest that estimates of asthma among Hispanic schoolchildren might be low because of underdiagnosis among children whose parents prefer communicating in Spanish.

Key words: Hispanic, asthma, pediatrics, language, school

Abbreviations used: BPAS+, Brief Pediatric Asthma Screen Plus, IRB, Institutional review board, NHIS, National Health Interview Survey

 

In the United States the largest and fastest-growing minority group is composed of Hispanic persons less than 18 years old.1 In 2003, 19% of US children and adolescents were of Hispanic descent, up from 9% in 1980.1 Overall, 68% of Hispanic children and adolescents come from households in which English is not the primary language.1 In Census 2000, 13.8 million (49%) of the 28.1 million Spanish speakers in the United States older than 4 years spoke English “less than very well.”2 English proficiency in the Hispanic population is important to consider when evaluating health outcomes and disparities because US health care delivery is provided largely by monolingual English speakers.3, 4, 5

Asthma serves as a good model for exploring the effect of language barriers on the health of Hispanic persons. Asthma is the most common chronic illness among children, and documented disparities exist between racial/ethnic groups.6, 7, 8, 9, 10, 11, 12, 13, 14 According to the 2004 National Health Interview Survey (NHIS), 11.3% of white children, 17.2% of African American children, and 10.4% of Hispanic children less than 18 years old have ever received a diagnosis of asthma.15 Chicago has the third largest Hispanic population of all cities in the United States, at 26%, behind only New York City and Los Angeles.16 Hispanic children comprise 38% of public elementary school children in Chicago, and 20% live below the national poverty line.17

The goal of this study was to document the effect of parental language preference (Spanish or English) on receiving a diagnosis of asthma in a large cohort of Chicago public and Catholic elementary and middle school children.

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Methods 

Study design and sample 

Our initial step in recruiting a community sample of children and adults with persistent asthma for a prospective cohort study (Chicago Initiative to Raise Asthma Health Equity) was implementing a cross-sectional survey screening for asthma among children attending Chicago public and Catholic elementary and middle schools during the 2003-2004 and 2004-2005 school years. Schools were eligible for screening if they had not had on-site asthma screening within the previous 2 years and the school principal agreed. The sampling pool of 531 schools had a student body size of 317,187 students. The institutional review boards (IRBs) of Northwestern University and the Cook County Bureau of Health Services approved the screening protocol. The Chicago Public School board and the Archdiocese of Chicago approved the screening protocol in their respective schools on the condition that approval from each school's principal was obtained.

Our primary sampling strategy for selecting schools was population-proportionate sampling after stratification into 2 race and income categories. To allow for future community-based interventions, we supplemented our sample with 40 schools selected by using cluster methodology (ie, geographic proximity to 20 randomly selected schools in our sample). Once a school was selected and the principal agreed to participate, a take-home survey was distributed to all children. Because of IRB requirements, no data were collected for children who did not return surveys.

In the final sample of 105 schools, we received 48,917 completed surveys and assessed them for eligibility. We selected children for this analysis who were of Hispanic ethnicity, were 6 to 12 years old, and had a parent who completed the survey. We restricted the age to 6 to 12 years because the asthma-screening instrument has been validated in Spanish and English for this age range.

Measures 

The 1-page survey instrument had 4 primary components: social-demographic characteristics of the child and caregiver, an asthma-screening tool (the Brief Pediatric Asthma Screen Plus [BPAS+]),18, 19 a question to identify asthma among household members, and a question box to express the household's interest in being contacted for a secondary screening for possible enrollment onto the longitudinal cohort. The social-demographic characteristics of the child included the following: age, age at time of asthma diagnosis, sex, and race/ethnicity. Self-reported race/ethnicity were coded as “any Hispanic,” “African American, non-Hispanic,” “white, non-African American and non-Hispanic,” and “other.” The caregiver reported his or her age and relationship to the child, as well as the ages and names of other household members with asthma. The survey was printed in English on one side and Spanish on the other. Parental language preference was defined as the language in which the parent completed the survey.

School variables were abstracted from the 2002-2003 school census databases and included student body size, type of school (public or Catholic), proportion of Hispanic children in the student body, and proportion of the student body that qualified for lunch subsidy. A child is eligible for the subsidized school lunch program if his or her family's annual income is 1.85 times the poverty line ($19,350 for a family of 4) or less.20

Asthma outcomes 

The 2 main outcome measures, asthma diagnosis and undiagnosed possible asthma, were assessed by using the BPAS+ instruments in English and Spanish.18, 19 The instruments have been validated in low-income populations by comparing the results with medical histories and the findings of physical examinations conducted by pediatric asthma specialists. Like the NHIS, the BPAS+ asks the caregiver the following question: “Has a doctor or nurse ever told you that your child has asthma?”15 The caregiver is also asked to respond to 4 respiratory symptom questions. The sensitivity and specificity of the BPAS+ are based on the performance of the symptom questions. Optimal scoring for further evaluation for undiagnosed possible asthma is achieved with a positive response to 1 or more of the following 4 items: wheeze, persistent cough, night cough, and breathing problem with temperature change. In our study the sensitivity and specificity of English BPAS+ for black subjects were 73% and 74%, respectively, and for Hispanic subjects, they were 61% and 83%, respectively. The Spanish BPAS+ had 74% sensitivity and 86% specificity.18, 19 Responses to the BPAS+ items were used to classify each child into one of the 3 following categories: (1) the child shows no symptoms and has no diagnosis of asthma, (2) the child shows symptoms of asthma but has no diagnosis (undiagnosed possible asthma), and (3) the child previously received a diagnosis of asthma.18, 19

Statistical analysis 

We conducted bivariate analyses of associations between parental language preference and each social-demographic characteristic of the children, parental asthma status, presence of another household member with asthma, and the study asthma outcome using χ2 and t tests, as appropriate. Multivariate analysis proceeded with logistic regression to model asthma status. Our model compared children with diagnosed asthma with children with possible asthma. Our final logistic regression model was chosen based on goodness of fit (assessed by using the Hosmer-Lemesbow test statistic21) and area under the receiver operating characteristic curve. Within-school correlation was accounted for by computing robust SEs for all model parameters estimated clustered by school. All study analyses were performed with STATA software, version 9.2 (StataCorp, College Station, Tex).22

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Results 

The school participation rate was 79.5% (105/132); 27 principals denied permission for screening. Compared with participating schools, the 27 nonparticipating schools had a greater proportion of Hispanic students (37% vs 55%, P < .001) and more students qualifying for subsidized lunches (71% vs 76%, P < .001). Nonparticipating schools did not differ from participating schools in the proportion that was Catholic (30% vs 26%, P = .68) or in mean student body size (793 vs 612, P = .09).

The overall rate of completed surveys returned was 78.9%, ranging from 39.6% to 99.4%. After excluding 1001 (2.1%) children who returned surveys completed by someone other than a parent, our final sample was 14,177 Hispanic children 6 to 12 years old. The majority of surveys (61.3%) were completed in English, whereas 38.7% were completed in Spanish (Table I). Of all children, 49.5% were boys, and 50.5% were girls, with a mean age of 8.8 years (SD, 1.95).

Table I. Characteristics of Hispanic children included in the study sample
CharacteristicTotal (n = 14,177)At risk of an asthma diagnosis∗ (n = 3,500)Diagnosis of asthma (n = 1,700)
Male sex [n (%) of children]7022 (49.5)1910 (54.6)982 (57.8)
Female sex [n (%) of children]7155 (50.5)1590 (45.4)718 (42.2)
Child age [mean no. of years (SD)]8.8 (1.9)8.7 (1.9)8.9 (1.9)
Parental language preference
Spanish [n (%) of children]5486 (38.7)1223 (34.9)444 (26.1)
English [n (%) of children]8691 (61.3)2277 (65.1)1256 (73.9)
Household asthma†
No. (%) of children with a parent with asthma1019 (7.3)572 (16.6)419 (24.9)
No. (%) of children with household member with a asthma besides child and parent2213 (15.8)934 (27.0)616 (36.6)

∗All children with either a diagnosis of asthma or symptoms of asthma.

†Number of children missing data for parental asthma and other household members with asthma: total sample, 176; all children at risk of an asthma diagnosis, 45; diagnosed asthma sample, 16.

Overall, 1700 (12.0%) Hispanic children had diagnosed asthma. Asthma diagnosis was more common among boys than girls (14.0% vs 10.0%, P < .001). The median age at diagnosis was 4 years. Parental language preference was associated with diagnosed asthma. Of children whose surveys were completed in English, 14.5% (1256/8691) had diagnosed asthma, whereas of children whose surveys were completed in Spanish, 8.1% (444/5486) had diagnosed asthma (P < .001). More than one third of children with diagnosed asthma came from households with at least 1 other person with asthma (Table I).

Among the 3500 children at risk of an asthma diagnosis (both diagnosed asthma and possible asthma), 1223 (35%) parents completed the survey in Spanish, and 2277 (65%) completed the survey in English. Of those at risk for an asthma diagnosis, 444 (36%) of 1223 children with Spanish-preference parents received a diagnosis of asthma compared with 1256 (55%) of 2277 children with English-preference parents (P < .001).

A logistic model was conducted to determine characteristics associated with diagnosed asthma in children at risk (Table II). Parents who completed the survey in English were more likely to report an asthma diagnosis (odds ratio, 1.82; 95% CI, 1.63-2.00). Children with diagnosed asthma were more likely to be boys, have a parent who has asthma, and have at least 1 additional household member with asthma. There was no association with age of child. The area under the receiver operating characteristic curve was 0.68.

Table II. Logistic regression model of diagnosed asthma in Hispanic children at risk for an asthma diagnosis
VariableDiagnosed asthma in Hispanic children at risk for an asthma diagnosis [OR (95% CI)]
Male sex1.32 (1.16-1.51)
Age1.08 (1.06-1.10)
Parent with English-language preference1.82 (1.64-2.02)
Parent with asthma2.62 (2.21-3.10)
Other household member with asthma (besides child and parent)2.18 (1.98-2.41)

OR, Odds ratio.

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Discussion 

In this study we found an important relationship between parental language preference and asthma diagnosis in a large cohort of Hispanic schoolchildren. Our analyses (ie, children with diagnosed asthma compared with children at risk of an asthma diagnosis) revealed that rates of diagnosed asthma were greater among children whose surveys were completed in English compared with those among children whose surveys were completed in Spanish. In contrast, children whose surveys were completed in Spanish were more likely to have symptoms consistent with asthma without an asthma diagnosis. Several factors might contribute to this result, including being uninsured; having limited access to high-quality care (even when insured); acculturation effects on knowledge, experience, beliefs, and behaviors related to health and illness; and communication barriers.

Being uninsured can limit opportunities of receiving a diagnosis of asthma.23 Of all racial/ethnic groups in the United States, Hispanic children are the least likely to be insured. Compared with 11.1% of white children, 13.9% of black children, and 11.5% of Asian children, 22.7% of Hispanic children are uninsured.24 Furthermore, foreign-born Spanish-speaking Hispanic persons are less likely than English-speaking Hispanic persons to have insurance.25, 26, 27, 28 In a predominantly Hispanic community in California, Granados et al26 found that, among English-speaking US-born parents and children, 90% of children were insured and 95% had routine access to health care. Among non–US-born parents and children (69% Spanish-speaking caregivers), 36% of children were insured, and 68% had routine access to health care.

When Hispanic children are insured, several studies suggest that Hispanics can have difficulty obtaining high-quality health care, which might lead to underdiagnosis or undertreatment of important chronic conditions.29, 30, 31 In a large sample of children from pediatric practices, Hispanic children were less likely (56%) to undergo vision screening compared with Asian (71%), white (66%), and black (63%) children.29 A medical record review of hospitalized patients 1 to 6 years old with asthma found that black and Hispanic subjects were less likely to have taken inhaled β-agonists or anti-inflammatory medications before hospital admission and less likely to have been prescribed a nebulizer for home use at hospital discharge than white subjects. Adjusted analyses revealed that primary care practice type accounted for the differences in preventive treatments, yet the differences in posthospitalization care remained significant with respect to race.30 A third study surveyed parents of 1002 children with asthma, focusing on the child's use of asthma medication over the past 12 months. This retrospective study found that Hispanic children received significantly fewer inhaled steroids than white children.31

A survey completed in Spanish might indicate someone with less acculturation to the United States.28, 32 Individuals who are less acculturated bring knowledge, experience, beliefs, and behaviors regarding health care from their culture of origin. In US cities, because of public health messages and personal encounters with asthma, unfamiliarity with asthma is unlikely, but the experience of Hispanic subjects might be different.33 For example, one study found that Hispanic mothers believed that a child's asthma was gone when the symptoms disappeared, a misconception that is not limited to Hispanic subjects but that nonetheless might cause parental underreporting of children's symptoms.34 As suggested by a study of focus groups that included immigrant Hispanic parents, grandparents, and community health care workers caring for children with asthma, cultural stigma associated with asthma or hesitancy to accept the diagnosis as an explanation for the symptoms might contribute to underreporting.33 In the focus groups of Spanish speakers, instead of mentioning explicitly a diagnosis of asthma, Hispanic parents used vague terms and described their children as having respiratory problems. It is entirely possible that less-acculturated Hispanics have culturally based explanations for their children's symptoms. In these cases parents might avoid allopathic medical care, where providers are less knowledgeable of traditional Hispanic beliefs, preferring traditional healers instead. Embracing folk medicines and home remedies, as well as educating patients on the potential benefits and adverse effects of modern prescription drugs, might enable health care providers to bridge this cultural gap.33, 34, 35, 36, 37

Communicating with health care providers is a major obstacle for Spanish speakers that might lead to underdiagnosis of asthma. Although interpreters are often available, the quality of services delivered with the assistance of one varies and depends on his or her training. Interpreter services can be provided by bilingual staff, staff interpreters, or outside services, including remote telephonic or video interpreters.35 Where interpreters are unavailable or quality of interpretation is poor, Spanish-speaking Hispanic subjects are less likely to have a stable source of care and to be offered follow-up appointments at discharge from the emergency department and are more likely to receive fewer preventative services, to receive more misdiagnoses and inappropriate treatments, and to not receive proper explanations of adverse effects of medications.27, 35, 38, 39 Underreporting in our study might have been caused by parents never being told that their child has asthma or by parents experiencing miscommunication regarding a diagnosis.33

Our study found a relationship between household asthma and an asthma diagnosis in Hispanic children that is consistent with findings of previous studies.40, 41, 42, 43 Possible explanations for higher rates of diagnosed asthma in children when either a parent or other household member has a diagnosis of asthma include genetic factors and household asthma knowledge. The Chicago Asthma Surveillance Initiative Project Team documented that a higher level of family, household, or both asthma experience is correlated with increased personal asthma knowledge.44 Higher asthma knowledge in a caregiver, in turn, might be correlated with an increased likelihood of a child receiving a diagnosis of asthma. Thus a combination of genetic factors, symptom awareness, and diagnosis-seeking behavior might account for a higher rate of asthma in a household, increasing the likelihood of a child with asthma receiving a diagnosis. Perhaps it should be of concern that in our study families including a child with undiagnosed possible asthma, like families including a child with a diagnosis of asthma, were more likely also to have other family members with a diagnosis of asthma. A limitation to our study is that our survey did not inquire whether these children had been evaluated by a health care provider for asthma symptoms without receiving a diagnosis of asthma, as well as whether the family sought further evaluation of asthma symptoms.

There are other important limitations to our study. First, we have no data for children who did not return a survey completed by a parent. A child's not returning a survey was interpreted as a passive refusal to participate, and the IRBs prohibited additional attempts to contact these students. A few schools had large numbers of children from Poland or China whose parents were likely unable to complete the survey because of limited English or Spanish proficiency. Even among English speakers, literacy might have been a barrier to survey completion. We considered this fact at the onset of the study by writing the English version of the survey at a third-grade reading level, according to Flesch-Kincaid criteria for readability.45, 46, 47 The manner in which we collected data regarding Hispanic ethnicity is an additional limitation. Although Hispanic subjects share a common language, there is significant diversity with respect to culture, country of origin, genetic ancestry, socioeconomic status, education, and documented variation in the rate of asthma by subgroup.48, 49, 50, 51 Although we did not use a professional evaluation to identify undiagnosed possible asthma (like most other studies), we used a survey with known sensitivity and specificity that was printed in English and Spanish.18, 19 Similar to the NHIS, we recorded parents' reports of professional diagnoses of asthma, a method widely used for asthma epidemiology in the United States.15 Nonetheless, it is possible that cultural factors associated with parental language preference might have contributed to underreporting of an asthma diagnosis in the child.

We have demonstrated a strong relationship between parental preference for English and diagnosed asthma and the opposite relationship between parental preference for Spanish and undiagnosed possible asthma, suggesting that underdiagnosis among Hispanic subjects might be a great public health problem. In addition to collecting data regarding Hispanic subgroup, acculturation level, and socioeconomic status, additional research of asthma outcomes in Hispanic children should endeavor to collect data on language preference for parents and children because our study demonstrates that it might be an important factor. Although we can speculate on the role of language, the relationship between language preference and asthma health care outcomes deserves additional focus.

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 Supported by a grant from the National Heart, Lung, and Blood Institute (1-U01 HL 72496-1) sponsoring the Chicago Initiative to Raise Asthma Health Equity.

 Disclosure of potential conflict of interest: G. S. Mosnaim has consulting arrangements with GlaxoSmithKline, owns stock in Electrocore, and is on the speakers' bureau for the Respiratory and Allergic Disease Foundation, Sanofi-Aventis, Schering-Plough, Merck, GlaxoSmithKline, and AstraZeneca. R. A. Durazo-Arvizu and J. J. Shannon have received grant support from the National Heart, Lung, and Blood Institute. L. M. Curtis has received grant support from the National Institutes of Health. The rest of the authors have declared that they have no conflict of interest.

PII: S0091-6749(07)01640-5

doi:10.1016/j.jaci.2007.08.040

The Journal of Allergy and Clinical Immunology
Volume 120, Issue 5 , Pages 1160-1165, November 2007

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