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Parental language and asthma among urbanHispanic children

Giselle S. Mosnaim, MD, MS,a Laura S. Sadowski, MD, MPH,b Ramon A. Durazo-Arvizu,

PhD,c Lisa K. Sharp, PhD,d Laura M. Curtis, MS,e Madeleine U. Shalowitz, MD, MBA,f

John J. Shannon, MD,g and Kevin B. Weiss, MDe Chicago, Ill

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

From athe Department of Immunology and Microbiology, Rush Medical

College; bthe Collaborative Research Unit, Department of Medicine,

Cook County Bureau of Health Services and Rush Medical College; cthe

Department of Preventive Medicine and Epidemiology, Loyola University

Stritch School of Medicine; dthe Department of Medicine, Section of

Health Promotion Research, University of Illinois at Chicago; ethe

Institute for Healthcare Studies, Northwestern University; fEvanston

Northwestern Healthcare, Northwestern University Feinberg School of

Medicine; and gthe Divisions of Pulmonary and Critical Care Medicine,

Stroger Hospital of Cook County.

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 arrange-

ments with GlaxoSmithKline,ownsstock inElectrocore, 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.

Received for publication October 2, 2006; revised August 22, 2007; accepted

for publication August 22, 2007.

Reprint requests: Giselle Mosnaim, MD, MS, Department of Immunology and

Microbiology, Rush Medical College, 1725 West Harrison, Suite 117,

Chicago, IL 60612. E-mail: gmosnaim@rush.edu.

0091-6749/$32.00

� 2007 American Academy of Allergy, Asthma & Immunology

doi:10.1016/j.jaci.2007.08.040

1160

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. (J Allergy Clin Immunol

2007;120:1160-5.)

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

In the United States the largest and fastest-growingminority group is composed of Hispanic persons less than18 years old.1 In 2003, 19% of US children and adoles-cents were of Hispanic descent, up from 9% in 1980.1

Overall, 68% of Hispanic children and adolescents comefrom households in which English is not the primarylanguage.1 In Census 2000, 13.8 million (49%) of the28.1 million Spanish speakers in the United States olderthan 4 years spoke English ‘‘less than very well.’’2

English proficiency in the Hispanic population is impor-tant to consider when evaluating health outcomes anddisparities because US health care delivery is providedlargely by monolingual English speakers.3-5

Asthma serves as a good model for exploring the effectof language barriers on the health of Hispanic persons.Asthma is the most common chronic illness amongchildren, and documented disparities exist between racial/ethnic groups.6-14 According to the 2004 National HealthInterview Survey (NHIS), 11.3% of white children,17.2% of African American children, and 10.4% ofHispanic children less than 18 years old have everreceived a diagnosis of asthma.15 Chicago has the third larg-est 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 elementaryschool children in Chicago, and 20% live below the nationalpoverty line.17

The goal of this study was to document the effect ofparental language preference (Spanish or English) onreceiving a diagnosis of asthma in a large cohort ofChicago public and Catholic elementary and middleschool children.

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

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Abbreviations usedBPAS1: Brief Pediatric Asthma Screen Plus

IRB: Institutional review board

NHIS: National Health Interview Survey

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 popula-

tion-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 [BPAS1]),18,19

a question to identify asthma among household members, and a ques-

tion box to express the household’s interest in being contacted for a

secondary screening for possible enrollment onto the longitudinal co-

hort. 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 re-

lationship 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 BPAS1 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 BPAS1 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 BPAS1 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 BPAS1 for black subjects were 73% and 74%, respectively,

and for Hispanic subjects, they were 61% and 83%, respectively.

The Spanish BPAS1 had 74% sensitivity and 86% specificity.18,19

Responses to the BPAS1 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 x2 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 lo-

gistic regression model was chosen based on goodness of fit (assessed

by using the Hosmer-Lemesbow test statistic21) and area under the re-

ceiver operating characteristic curve. Within-school correlation was

accounted for by computing robust SEs for all model parameters esti-

mated clustered by school. All study analyses were performed with

STATA software, version 9.2 (StataCorp, College Station, Tex).22

RESULTS

The school participation rate was 79.5% (105/132); 27principals denied permission for screening. Comparedwith participating schools, the 27 nonparticipating schoolshad a greater proportion of Hispanic students (37% vs55%, P < .001) and more students qualifying for subsi-dized lunches (71% vs 76%, P < .001). Nonparticipatingschools did not differ from participating schools in theproportion that was Catholic (30% vs 26%, P 5 .68) orin mean student body size (793 vs 612, P 5 .09).

The overall rate of completed surveys returned was78.9%, ranging from 39.6% to 99.4%. After excluding1001 (2.1%) children who returned surveys completed bysomeone other than a parent, our final sample was 14,177Hispanic children 6 to 12 years old. The majority ofsurveys (61.3%) were completed in English, whereas38.7% were completed in Spanish (Table I). Of all chil-dren, 49.5% were boys, and 50.5% were girls, with amean age of 8.8 years (SD, 1.95).

Overall, 1700 (12.0%) Hispanic children had diagnosedasthma. Asthma diagnosis was more common among boysthan girls (14.0% vs 10.0%, P < .001). The median age atdiagnosis was 4 years. Parental language preference wasassociated with diagnosed asthma. Of children whose sur-veys were completed in English, 14.5% (1256/8691) had

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TABLE I. Characteristics of Hispanic children included in the study sample

Characteristic

Total

(n 5 14,177)

At risk

of an asthma

diagnosis* (n 5 3,500)

Diagnosis

of asthma

(n 5 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 asthma 1019 (7.3) 572 (16.6) 419 (24.9)

No. (%) of children with household member with a asthma besides child and parent 2213 (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.

diagnosed asthma, whereas of children whose surveyswere completed in Spanish, 8.1% (444/5486) had diag-nosed asthma (P < .001). More than one third of childrenwith diagnosed asthma came from households with at least1 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 foran asthma diagnosis, 444 (36%) of 1223 children withSpanish-preference parents received a diagnosis of asthmacompared with 1256 (55%) of 2277 children with English-preference parents (P < .001).

A logistic model was conducted to determine charac-teristics associated with diagnosed asthma in children atrisk (Table II). Parents who completed the survey inEnglish were more likely to report an asthma diagnosis(odds ratio, 1.82; 95% CI, 1.63-2.00). Children with diag-nosed asthma were more likely to be boys, have a parentwho has asthma, and have at least 1 additional householdmember with asthma. There was no association with ageof child. The area under the receiver operating character-istic curve was 0.68.

DISCUSSION

In this study we found an important relationshipbetween parental language preference and asthma diag-nosis in a large cohort of Hispanic schoolchildren. Ouranalyses (ie, children with diagnosed asthma comparedwith children at risk of an asthma diagnosis) revealed thatrates of diagnosed asthma were greater among childrenwhose surveys were completed in English compared withthose among children whose surveys were completed inSpanish. In contrast, children whose surveys were com-pleted in Spanish were more likely to have symptomsconsistent with asthma without an asthma diagnosis.Several factors might contribute to this result, includingbeing uninsured; having limited access to high-qualitycare (even when insured); acculturation effects on

knowledge, experience, beliefs, and behaviors related tohealth and illness; and communication barriers.

Being uninsured can limit opportunities of receiving adiagnosis of asthma.23 Of all racial/ethnic groups in theUnited States, Hispanic children are the least likely to beinsured. 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, for-eign-born Spanish-speaking Hispanic persons are lesslikely than English-speaking Hispanic persons to haveinsurance.25-28 In a predominantly Hispanic communityin California, Granados et al26 found that, amongEnglish-speaking US-born parents and children, 90% ofchildren were insured and 95% had routine access tohealth care. Among non–US-born parents and children(69% Spanish-speaking caregivers), 36% of childrenwere insured, and 68% had routine access to health care.

When Hispanic children are insured, several studiessuggest that Hispanics can have difficulty obtaining high-quality health care, which might lead to underdiagnosisor undertreatment of important chronic conditions.29-31

In a large sample of children from pediatric practices,Hispanic children were less likely (56%) to undergo visionscreening compared with Asian (71%), white (66%), andblack (63%) children.29 A medical record review of hospi-talized patients 1 to 6 years old with asthma found thatblack and Hispanic subjects were less likely to have takeninhaled b-agonists or anti-inflammatory medicationsbefore hospital admission and less likely to have been pre-scribed a nebulizer for home use at hospital discharge thanwhite subjects. Adjusted analyses revealed that primarycare practice type accounted for the differences in preven-tive treatments, yet the differences in posthospitalizationcare remained significant with respect to race.30 A thirdstudy surveyed parents of 1002 children with asthma,focusing on the child’s use of asthma medication overthe past 12 months. This retrospective study found thatHispanic children received significantly fewer inhaledsteroids than white children.31

A survey completed in Spanish might indicate some-one with less acculturation to the United States.28,32

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Individuals who are less acculturated bring knowledge,experience, beliefs, and behaviors regarding health carefrom their culture of origin. In US cities, because of publichealth messages and personal encounters with asthma, un-familiarity with asthma is unlikely, but the experience ofHispanic subjects might be different.33 For example, onestudy found that Hispanic mothers believed that a child’sasthma was gone when the symptoms disappeared, a mis-conception that is not limited to Hispanic subjects butthat nonetheless might cause parental underreporting ofchildren’s symptoms.34 As suggested by a study of focusgroups that included immigrant Hispanic parents, grand-parents, and community health care workers caring forchildren with asthma, cultural stigma associated withasthma or hesitancy to accept the diagnosis as an explana-tion for the symptoms might contribute to underreport-ing.33 In the focus groups of Spanish speakers, insteadof mentioning explicitly a diagnosis of asthma, Hispanicparents used vague terms and described their children ashaving respiratory problems. It is entirely possible thatless-acculturated Hispanics have culturally based explana-tions for their children’s symptoms. In these cases parentsmight avoid allopathic medical care, where providers areless knowledgeable of traditional Hispanic beliefs, prefer-ring traditional healers instead. Embracing folk medicinesand home remedies, as well as educating patients on thepotential benefits and adverse effects of modern prescrip-tion drugs, might enable health care providers to bridgethis cultural gap.33-37

Communicating with health care providers is a majorobstacle for Spanish speakers that might lead to under-diagnosis of asthma. Although interpreters are oftenavailable, the quality of services delivered with theassistance of one varies and depends on his or her training.Interpreter services can be provided by bilingual staff,staff interpreters, or outside services, including remotetelephonic or video interpreters.35 Where interpreters areunavailable or quality of interpretation is poor, Spanish-speaking Hispanic subjects are less likely to have a stablesource of care and to be offered follow-up appointments atdischarge from the emergency department and are morelikely to receive fewer preventative services, to receivemore misdiagnoses and inappropriate treatments, and tonot receive proper explanations of adverse effects of med-ications.27,35,38,39 Underreporting in our study might havebeen caused by parents never being told that their child hasasthma or by parents experiencing miscommunicationregarding a diagnosis.33

Our study found a relationship between householdasthma and an asthma diagnosis in Hispanic childrenthat is consistent with findings of previous studies.40-43

Possible explanations for higher rates of diagnosed asthmain children when either a parent or other household mem-ber has a diagnosis of asthma include genetic factors andhousehold asthma knowledge. The Chicago AsthmaSurveillance Initiative Project Team documented that ahigher level of family, household, or both asthma experi-ence is correlated with increased personal asthma knowl-edge.44 Higher asthma knowledge in a caregiver, in turn,

might be correlated with an increased likelihood of achild receiving a diagnosis of asthma. Thus a combinationof genetic factors, symptom awareness, and diagnosis-seeking behavior might account for a higher rate of asthmain a household, increasing the likelihood of a child withasthma receiving a diagnosis. Perhaps it should be ofconcern that in our study families including a child withundiagnosed possible asthma, like families including achild with a diagnosis of asthma, were more likely alsoto have other family members with a diagnosis of asthma.A limitation to our study is that our survey did not inquirewhether these children had been evaluated by a health careprovider for asthma symptoms without receiving a diag-nosis of asthma, as well as whether the family soughtfurther evaluation of asthma symptoms.

There are other important limitations to our study. First,we have no data for children who did not return a surveycompleted by a parent. A child’s not returning a surveywas interpreted as a passive refusal to participate, and theIRBs prohibited additional attempts to contact thesestudents. A few schools had large numbers of childrenfrom Poland or China whose parents were likely unable tocomplete the survey because of limited English or Spanishproficiency. Even among English speakers, literacy mighthave been a barrier to survey completion. We consideredthis fact at the onset of the study by writing the Englishversion of the survey at a third-grade reading level,according to Flesch-Kincaid criteria for readability.45-47

The manner in which we collected data regardingHispanic ethnicity is an additional limitation. AlthoughHispanic subjects share a common language, there issignificant diversity with respect to culture, country oforigin, genetic ancestry, socioeconomic status, education,and documented variation in the rate of asthma bysubgroup.48-51 Although we did not use a professionalevaluation to identify undiagnosed possible asthma (likemost other studies), we used a survey with known sensi-tivity and specificity that was printed in English andSpanish.18,19 Similar to the NHIS, we recorded parents’ re-ports of professional diagnoses of asthma, a method widelyused for asthma epidemiology in the United States.15

Nonetheless, it is possible that cultural factors associatedwith parental language preference might have contributedto underreporting of an asthma diagnosis in the child.

TABLE II. Logistic regression model of diagnosed asthma

in Hispanic children at risk for an asthma diagnosis

Variable

Diagnosed asthma

in Hispanic children

at risk for an asthma

diagnosis [OR (95% CI)]

Male sex 1.32 (1.16-1.51)

Age 1.08 (1.06-1.10)

Parent with English-language preference 1.82 (1.64-2.02)

Parent with asthma 2.62 (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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We have demonstrated a strong relationship betweenparental preference for English and diagnosed asthma andthe opposite relationship between parental preference forSpanish and undiagnosed possible asthma, suggesting thatunderdiagnosis among Hispanic subjects might be a greatpublic health problem. In addition to collecting dataregarding Hispanic subgroup, acculturation level, andsocioeconomic status, additional research of asthma out-comes in Hispanic children should endeavor to collectdata on language preference for parents and childrenbecause our study demonstrates that it might be animportant factor. Although we can speculate on the roleof language, the relationship between language preferenceand asthma health care outcomes deserves additionalfocus.

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