Lauren A. Smith

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

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

Modifiable Risk Factors for Suboptimal Control and Controller Medication Underuse Among Children With Asthma

OBJECTIVES. Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes. METHODS. We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as ≥4 symptom days, ≥1 symptom night, or ≥4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse. RESULTS. Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications. CONCLUSIONS. Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.

Trends and Factors Associated With Infant Bed Sharing, 1993-2010: The National Infant Sleep Position Study

IMPORTANCE A strong association between infant bed sharing and sudden infant death syndrome or unintentional sleep-related death in infants has been established. Occurrences of unintentional sleep-related deaths among infants appear to be increasing. OBJECTIVES To determine the trends and factors associated with infant bed sharing from 1993 through 2010, including the association of physician advice on bed sharing. DESIGN National Infant Sleep Position study conducted with annual telephone surveys. SETTING The 48 contiguous states. PARTICIPANTS Nighttime caregivers of infants born within 7 months of each survey administration. Approximately 1000 interviews were completed annually. MAIN OUTCOMES AND MEASURES Infant bed sharing as a usual practice. RESULTS Of 18 986 participants, 11.2% reported an infant sharing a bed as a usual practice. Bed sharing increased from 1993 (6.5%) to 2010 (13.5%). Although bed sharing increased significantly among white respondents from 1993 to 2000 (P < .001), the increase from 2001 to 2010 was not significant (P = .48). Black and Hispanic respondents reported an increase in bed sharing throughout the study period, with no difference between the earlier and later periods (P = .63 and P = .77, respectively). After accounting for the study year, factors associated with increase in infant bed sharing as a usual practice included maternal educational level of less than high school compared with college or greater (adjusted odds ratio, 1.42 [95% CI, 1.12-1.79]); black (3.47 [2.97-4.05]), Hispanic (1.33 [1.10-1.61]), and other (2.46 [2.03-2.97]) maternal race or ethnicity compared with white race; household income of less than

Sickle Cell Disease: A Question of Equity and Quality

20,000 (1.69 [1.44-1.99]) and

Trends and factors associated with infant sleeping position: the national infant sleep position study, 1993-2007

20,000 to

Sleep Duration, Restfulness, and Screens in the Sleep Environment

50,000 (1.29 [1.14-1.45]) compared with greater than

Employment Barriers Among Welfare Recipients and Applicants With Chronically Ill Children

50,000; living in the West (1.61 [1.38-1.88]) or the South (1.47 [1.30-1.66]) compared with the Midwest; infants younger than 8 weeks (1.45 [1.21-1.73]) or ages 8 to 15 weeks (1.31 [1.17-1.45]) compared with 16 weeks or older; and being born prematurely compared with full-term (1.41 [1.22-1.62]). Almost 46% of the participants reported talking to a physician about bed sharing. Compared with those who did not receive advice from a physician, those who reported their physicians had a negative attitude were less likely to have the infant share a bed (adjusted odds ratio, 0.66 [95% CI, 0.53-0.82]), whereas a neutral attitude was associated with increased bed sharing (1.38 [1.05-1.80]). CONCLUSIONS AND RELEVANCE Our finding of a continual increase in bed sharing throughout the study period among black and Hispanic infants suggests that the current American Academy of Pediatrics recommendation about bed sharing is not universally followed. The factors associated with infant bed sharing may be useful in evaluating the impact of a broad intervention to change behavior.

Racial/Ethnic variation in parent perceptions of asthma.

Thirty years ago, the first major federal legislation concerning sickle cell disease treatment was passed, resulting in the development of comprehensive sickle cell centers. We are now at another watershed moment in the treatment of this illness with the passage in October 2004 of the Sickle Cell Treatment Act, designed to substantially expand specialized sickle cell treatment programs. This legislation offers a remarkable opportunity to significantly improve health outcomes for individuals with sickle cell disease if it is implemented with a specific focus on the distinct but related issues of equity and quality. Despite major advances in sickle cell disease treatment that have occurred over the past 3 decades, important gaps exist both in the equity of government and private philanthropic support for research and in the uniform provision of high quality clinical care. This article assesses the current gaps in funding support and in the implementation of improvements in clinical care in order to suggest strategies for making optimal use of the opportunity that the new legislation presents to improve the health of all individuals affected by this disease.

Early Diagnoses of Autism Spectrum Disorders in Massachusetts Birth Cohorts, 2001–2005

OBJECTIVE To determine trends and factors associated with choice of infant sleeping position. DESIGN Annual nationally representative telephone surveys from 1993 through 2007. SETTING Forty-eight contiguous states of the United States. PARTICIPANTS Nighttime caregivers of infants born within the last 7 months; approximately 1000 interviews were given each year. Main Outcome Measure Whether infant is usually placed supine to sleep. RESULTS For the 15-year period, supine sleep increased (P < .001) and prone sleep decreased (P < .001) for all infants, with no significant difference in trend by race. Since 2001, a plateau has been reached for all races. Factors associated with increased supine sleep between 1993 and 2007 included time, maternal race other than African American, higher maternal educational level, not living in Southern states, first-born infant, and full-term infant. The effect of these variables was reduced when variables related to maternal concerns about infant comfort, choking, and advice from physicians were taken into account. Between 2003 and 2007, there was no significant yearly increase in supine sleep. Choice of sleep position could be explained almost entirely by caregiver concern about comfort, choking, and advice. Race no longer was a significant predictor. CONCLUSIONS Since 2001, supine sleep has reached a plateau, and there continue to be racial disparities. There have been changes in factors associated with sleep position, and maternal attitudes about issues such as comfort and choking may account for much of the racial disparity in practice. To decrease sudden infant death syndrome rates, we must ensure that public health measures reach the populations at risk and include messages that address concerns about infant comfort and choking.

Low-Income Mothers' Experience with Poor Health, Hardship, Work, and Violence Implications for Policy

BACKGROUND AND OBJECTIVE: Associations of inadequate sleep with numerous health outcomes among youth necessitate identifying its modifiable determinants. Television (TV) has been associated with sleep curtailment, but little is known about small screens (eg, smartphones), which can be used in bed and emit notifications. Therefore, we examined associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. METHODS: Participants included 2048 fourth- and seventh-graders participating in the Massachusetts Childhood Obesity Research Demonstration Study in 2012 to 2013. Using linear and log binomial regression, we examined cross-sectional associations of small screens and TVs in sleep environments and screen time with weekday sleep duration and perceived insufficient rest or sleep in the past week. RESULTS: Children who slept near a small screen (compared with never) reported 20.6 fewer minutes of sleep (95% confidence interval [CI], −29.7 to −11.4) and had a higher prevalence of perceived insufficient rest or sleep (prevalence ratio, 1.39; 95% CI, 1.21 to 1.60). Children who slept in a room with a TV (compared with no TV) reported 18.0 fewer minutes of sleep (95% CI, −27.9 to −8.1). TV or DVD viewing and video or computer game playing were associated with both sleep outcomes (P < .01). Some associations were stronger among Hispanic, non-Hispanic black, and older children (P < .05 for heterogeneity). CONCLUSIONS: Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations. Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep. These findings caution against unrestricted screen access in children’s bedrooms.