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doi:10.1378/chest.06-1917
(Chest. 2007; 131:1331-1338)
© 2007 American College of Chest Physicians
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Area of Residence, Birthplace, and Asthma in Puerto Rican Children*

Robyn T. Cohen, MD, MPH; Glorisa J. Canino, PhD; Hector R. Bird, MD; Sa Shen, PhD; Bernard A. Rosner, PhD and Juan C. Celedón, MD, DrPH, FCCP

* From Channing Laboratory and Respiratory Disorders Program (Drs. Cohen, Rosner, and Celedón), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Behavioral Sciences Research Institute (Dr. Canino), University of Puerto Rico, San Juan, Puerto Rico; and Division of Child and Adolescent Psychiatry (Drs. Bird and Shen), Columbia University, New York, NY.

Correspondence to: Robyn T. Cohen, MD, MPH, Channing Laboratory, 181 Longwood Ave, Boston, MA 02115; e-mail: robyn.cohen{at}childrens.harvard.edu

Abstract

Rationale: Puerto Ricans have the highest prevalence of asthma among all ethnic groups in the United States. There have been no studies that directly compare the burden of asthma between Puerto Ricans living in Puerto Rico and those living in the mainland United States

Objective: To examine the relation between birthplace, area of residence, and asthma in Puerto Rican children.

Methods: Multistage population-based probability sample of children in the San Juan and Caguas metropolitan areas in Puerto Rico and in the Bronx, NY. Information was collected in a household survey of 2,491 children and their primary caretakers.

Results: The overall prevalence of asthma among Puerto Rican children in this study was very high (38.6%). Although children from Puerto Rico had higher socioeconomic status and lower rates of premature birth and prenatal smoke exposure, the prevalence of lifetime asthma was higher in Puerto Rican children living in Puerto Rico than in Puerto Rican children living in the South Bronx (41.3% vs 35.3%, p = 0.01). In multivariable analysis, residence in Puerto Rico was associated with increased odds of lifetime asthma (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.03 to 1.57) and lifetime hospitalization for asthma (OR, 1.47; 95% CI, 1.04–2.07).

Conclusions: Puerto Rican children in Puerto Rico had a higher risk of asthma than Puerto Rican children in the South Bronx, highlighting the need for further examination of the roles of migration, acculturation, and environmental and psychosocial factors on the development of asthma in this high-risk population.

Key Words: asthma • prevalence • Puerto Ricans

In the United States, Puerto Ricans have higher asthma prevalence and have more morbidity and mortality from asthma than do whites, blacks, and other Hispanic subgroups. Using data from the National Health Interview Survey for from 1997 to 2001, Lara et al1 showed that Puerto Rican children had a higher lifetime prevalence of asthma (25.8%) than did white (12.7%), black (15.8%), Mexican (10.1%), Cuban (14.9%), and Dominican (14.9%) children living in the mainland United States. In addition, mainland Puerto Rican children had increased odds of an asthma attack in the past 12 months. According to the 2002 Behavioral Risk Factor Surveillance System,2 the prevalence of current asthma was higher in adults living in Puerto Rico (11.6%) than in all US adults (7.3%) or Hispanic adults in the US mainland (5.5%). From 1990 to 1995, Puerto Ricans had the highest (40.9 per million) mortality rate due to asthma of all ethnic groups in the US mainland.3

New evidence suggests that the effect of birthplace on asthma in Puerto Ricans is opposite that found for other ethnic groups. Lara et al1 found that although birth outside the United States protected Mexican, other Hispanic, and non-Hispanic white children from receiving a diagnosis of asthma, the lifetime risk of an asthma diagnosis was higher for island-born Puerto Rican children living in the mainland United States than for mainland-born Puerto Rican children. There are studies45 demonstrating high prevalence, morbidity, and mortality from asthma among Puerto Ricans living in Puerto Rico, but none comparing the prevalence of asthma and health-care utilization for asthma among Puerto Rican children living in Puerto Rico with the prevalence and health-care utilization for asthma among Puerto Rican children living in the mainland United States. The main purpose of this study was to compare the prevalence of asthma and lifetime hospitalization for asthma among Puerto Rican children in urban communities in the mainland United States (South Bronx, NY) and in Puerto Rico (San Juan and Caguas metropolitan areas). In spite of a previous report,1 we hypothesized that there would be a higher prevalence of asthma in Puerto Rican children living in the South Bronx than in those living in Puerto Rico, mainly because of the widespread poverty and overall living conditions among children in the South Bronx. A secondary purpose of this study was to examine potential factors that might explain differences between the two populations.

Materials and Methods

This was a population-based prospective cohort study of the prevalence of antisocial behaviors and associated comorbid conditions (eg, asthma) among Puerto Rican children in each of two sites. Children in the South Bronx (New York) and the standard metropolitan areas of San Juan and Caguas (Puerto Rico) were enrolled from July 2001 through August 2003. The study was approved by the Institutional Review Boards of the New York State Psychiatric Institute and the University of Puerto Rico Medical School.

The study employed a multistage probability sample design described in detail elsewhere.6 Briefly, primary sampling units were randomly selected neighborhood clusters based on the 1990 US Census and subsequently adjusted to the 2000 census. Secondary sampling units were randomly selected households within each individual primary sampling unit. To contrast the prevalence of antisocial behaviors between island and mainland Puerto Rican children (the primary purpose of the original study), the sample size was calculated to be 1101 children per site in order to detect a risk ratio of 1.5 with 80% power at a p value <0.05.

A household was eligible if as follows: (1) at least one resident was a child between the ages of 5 and 13 years who was identified by his/her parents/primary caretakers as being of Puerto Rican background, and (2) at least one of the child’s parents or primary caretakers in the household also self-identified as being of Puerto Rican background. In households with more than one eligible child, a maximum of three children were randomly selected to participate. Children were not eligible if they had mental retardation or developmental disabilities, or if they had not resided in the household for at least 9 months.

Procedures
Families were invited to participate by trained interviewers who visited each randomly selected household. Initial contact was attempted up to six times per household. Informed consent was obtained from the parents of each participant. Structured questionnaire interviews were conducted in English and/or Spanish based on the preferences of the participants.

Measures
All measures included in this analysis were based on parent/guardian responses to interview questions. The study instrument was part of the Service Utilization and Risk Factors interview that was developed for the Epidemiology of Childhood and Mental Disorders Study7 for the purposes of assessing the presence of risk factors associated with mental illness. Psychometric properties of the specific components of the Service Utilization and Risk Factors interview (ie, medical history, sociodemographics)8 and methods used for cross-cultural adaptation and translation910 have been described elsewhere. Demographic data included the child’s age, gender, birthplace of the participants, birthplace of all grandparents of the participants, and indicators of socioeconomic status (SES) such as household income, use of public assistance, parental education, and parental marital status. Prenatal and perinatal information included gestational age, prenatal substance use by the mother, and perinatal complications. Information on the medical history and health-care use of the child was obtained. Parents were asked to respond "yes" or "no" to the questions "has your child ever had asthma?" and "has your child ever been hospitalized for asthma?"

Data Analysis
The samples were weighted to represent the age and gender distribution of the populations of Puerto Rican children in the South Bronx and the standard metropolitan areas in Puerto Rico on the basis of the 2000 US Census. Weighted analysis was conducted (SUDAAN Software, Version 8; Research Triangle Institute; Research Triangle Park, NC) to adjust SEs for intraclass correlations induced by multistage sampling, with children nested within households and households nested within primary sampling units. We used bivariate logistic regression to examine potential predictors of asthma and hospitalization for asthma. Multivariable logistic regression models were constructed by entering all bivariate predictors with p ≤ 0.20 followed by a backward stepwise selection procedure. Our primary predictors of interest were area of residence and birthplace. Other covariates remained in the final models if they were statistically significant (p < 0.05) or satisfied a change-in-estimate criterion (≥ 10% change in the measure of association).

Results

Figure 1 shows the schema for enrollment into the study by individual study site. Based on the sampling design, a total of 21,185 households were randomly selected for inclusion in the study; 20,681 households (97.6%) were successfully contacted. Of these 20,681 households, 1,853 households (9.0%) with 2,940 children were eligible for the study. However, 449 of 2,940 eligible children did not participate in the study because of parental refusal or repeated unavailability (three or more unsuccessful attempts). The final study population consisted of 2,491 children in 1,643 households. There were households with one (n = 1,009), two (n = 420), and three (n = 214) eligible children.


Figure 1
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  		Figure 1.. Enrollment of subjects.

 
Table 1 summarizes the characteristics of the study population. The denominator indicates the number of participants who provided valid information; missing values and "don’t know" were excluded from the calculations. Site of residence and birthplace were highly correlated: 90.2% of participants living in the Bronx were born in the mainland United States, and 94.6% of those living in Puerto Rico were born in Puerto Rico. Children living in Puerto Rico were more likely to have four grandparents who were born in Puerto Rico than Puerto Rican children living in the South Bronx. Families of Puerto Rican children in Puerto Rico were more likely to have household incomes < $25,000 per year but less likely to receive public assistance in the past year than families of Puerto Rican children in the South Bronx. Mothers of Puerto Rican children in Puerto Rico were more likely to have completed high school (HS) or a general equivalency diploma (GED) and less likely to smoke during pregnancy than mothers of Puerto Rican children in the South Bronx. Premature birth was lower in Puerto Rican children in Puerto Rico than in Puerto Rican children in the Bronx.


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  		Table 1.. Characteristics of the Study Population*

 
Table 2 shows bivariate analyses of the relation between variables of interest and asthma outcomes. Residence in Puerto Rico, birth in Puerto Rico, and premature birth were each significantly associated with increased odds of having had asthma and having been hospitalized for asthma. In contrast, female gender and age were inversely associated with asthma and having been hospitalized for asthma. SES indicators such as household income, maternal education, and parental marital status were not associated with asthma. However, marital status was inversely associated with a history of hospitalization for asthma. Maternal smoking during pregnancy was not associated with asthma or hospitalization for asthma.


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  		Table 2.. Bivariable Predictors of Asthma and Hospitalizations for Asthma

 
Table 3 shows the results of the multivariable analysis of the relation between the predictors and outcomes of interest. After adjustment for relevant covariates, residence in Puerto Rico and birth in Puerto Rico remained significant predictors of asthma. Residence in Puerto Rico was the primary predictor of interest in model 1, and birth in Puerto Rico was the primary predictor of interest in model 2. Similarly, in adjusted models, residence in Puerto Rico (model 3) and birth in Puerto Rico (model 4) were each significant predictors of asthma hospitalization among study participants (Table 4 ).


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  		Table 3.. Multivariable Analysis of the Association Between Area of Residence, Birthplace, and Asthma in Puerto Rican Children

 

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  		Table 4.. Multivariable Analysis of the Association Between Area of Residence, Birthplace, and Hospitalization for Asthma in Puerto Rican Children

 
Discussion

In our study, Puerto Rican children from the South Bronx were more likely to be born prematurely, to have mothers who smoked during pregnancy, and to have families with lower SES than island Puerto Rican children. Surprisingly, however, children living in Puerto Rico were more likely to have asthma and to have been hospitalized for asthma than Puerto Rican children living in the South Bronx.

Previous studies have demonstrated a high prevalence of asthma among children in Puerto Rico. Two separate probability sampled, community-based studies1112 of children in Puerto Rico found the lifetime prevalence of asthma to be > 30%. Perez-Perdomo et al5 found that parents of island Puerto Ricans who participated in the 2000 Behavioral Risk Factor Surveillance System reported a lifetime prevalence of asthma in their children of 33.2%. While many studies1314 have shown a high burden of asthma in mainland US cities in which a large proportion of the Hispanic population is of Puerto Rican background, fewer studies have focused on Puerto Ricans specifically.

Poverty is a common condition among Puerto Ricans1516; thus, most studies of asthma in the Puerto Rican population include participants from poor and disadvantaged backgrounds. It is unlikely, however, that the high prevalence of asthma in this population can be completely explained by issues related to SES. Ledogar at al17 found that the prevalence of asthma was higher in Puerto Ricans than in Dominicans or "other Latinos" living on the same streets and in the same buildings in Brooklyn, NY (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.0 to 3.6). Claudio et al18 conducted a study of 5,250 public elementary school children in New York City and found that Puerto Rican children had the highest 12-month prevalence of asthma (by parental report) of all ethnic groups, regardless of income level. Similarly, Ortega et al19 found no association between family income or maternal educational attainment and lifetime asthma prevalence, history of asthma attacks, or history of asthma hospitalization among children in Puerto Rico.

The finding of increased risk of asthma among island Puerto Ricans in this study was surprising for several reasons. Consistent with previous findings,20 premature birth (a significant risk factor for asthma)21222324 was more common in Puerto Rican children from the South Bronx than in those from Puerto Rico. Children from the South Bronx were also more likely to have been exposed to maternal cigarette smoking during pregnancy than children from Puerto Rico, and intrauterine smoke exposure has been associated with early wheeze,2526 asthma,2728 and more rapid decline in lung function.2930 Finally, families of Puerto Rican children in Puerto Rico had a lower household income than families of Puerto Rican children living in the South Bronx but were less likely to receive public assistance. Despite the universal health insurance provided to children in Puerto Rico by the health-care reform plan of 1998 ("La Reforma"), island Puerto Rican children may have had less contact with primary health-care providers and may have been underdiagnosed with asthma.31 However, island Puerto Rican children may have been more likely to seek care for wheeze and cough in the emergency department, thus making them more likely than children followed up over time by a primary care physician to receive a diagnosis of asthma based on one episode of respiratory symptoms.32

In contrast to our findings in Puerto Ricans, birth outside the United States has been inversely associated with asthma in Mexican Americans. In the Third National Health and Nutrition Examination Survey (NHANES III), parents were more likely to report asthma in Mexican-American children born in the United States than in Mexican-American children born in Mexico (OR, 3.2; 95% CI, 1.3 to 7.9).33 Holguin et al34 looked at 17,554 Mexican-American adults from NHANES III and the National Health Interview Survey. After adjustments for health-care access and other potential confounders, Mexican Americans born in the United States were found to be at higher risk for asthma than those born in Mexico (NHANES III: OR, 2.1; 95% CI, 1.4 to 3.3; National Health Interview Survey: OR, 2.7; 95% CI, 1.6 to 5.5). Potential explanations for the differential influence of birthplace on the risk of asthma developing among Puerto Ricans and Mexican Americans include variations in in utero or early childhood environmental exposures, sociocultural factors, or differences in migration patterns between the two groups.353637

There are several potential explanations for our findings that warrant further investigation. The findings of a study by Ledogar et al,17 in which children of different Latino backgrounds sharing the same environment had varying prevalence of asthma, suggest an underlying biological and/or genetic predisposition for asthma morbidity among Puerto Ricans.38 Although we found that children living in the Bronx were more likely to have at least one grandparent who was not born in Puerto Rico, there was no significant association between having all four grandparents born in Puerto Rico and an increased risk of asthma. Differences in environmental exposures are a possible explanation for a higher prevalence of asthma among island Puerto Rican children. Several studies3940 have reported on the high prevalence of asthma in tropical environments, which may be related to ambient conditions of temperature, humidity, air pollution, as well as exposure to specific environmental allergens such as Blomia tropicalis. Blomia is the dominant dust mite species in Puerto Rico,41 and studies4243 have found high numbers of children and adults in tropical environments that have become sensitized to this allergen. In addition, although we have information on in utero smoke exposure, we do not have information on current environmental tobacco smoke exposure. In a recent school-based study44 of childhood asthma in Northern Puerto Rico in which 46% of elementary school participants reported a lifetime history of asthma, approximately 30% of children lived with a smoker in the house.

One potential limitation of our study is that our primary outcome measure, lifetime prevalence of asthma, is based on parental report. The question "Has your child ever had asthma?" used in this study is taken directly from the previously validated International Study of Asthma and Allergies in Childhood questionnaire,4546 which has been used in 56 countries47 and has been validated in Spanish.48 Of note, a similar self-reported question for adults ("Have you ever had asthma?") has been used in the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms49 and the American Thoracic Society Division of Lung Disease50 questionnaires to assess asthma prevalence, and has been shown in multiple studies to have high sensitivity and specificity in differentiating asthmatics from nonasthmatics as compared to clinical diagnosis of asthma by a physician.51 Moreover, the finding that island Puerto Rican children were more likely than children in the South Bronx to be hospitalized for asthma supports our results regarding asthma prevalence.

A second limitation of our study is the lack of assessment of potential confounders, including upper respiratory tract infections, bronchiolitis, family history of asthma, environmental exposures, and allergen sensitization in participating children. Two studies have examined allergen sensitization in Puerto Rican children with asthma in the United States and in Puerto Rico. Celedón et al52 examined skin test reactivity (STR) to aeroallergens among asthmatic children in Hartford (CT). STR to cockroach, which was found in 44% of Puerto Rican children with asthma, was associated with increased asthma severity. Among Puerto Rican children, STR to dust mite (56%) and cat dander (47%) was also common. Similar findings were reported for asthmatic children in Ponce (Puerto Rico), where STR to dust mite (88%), cockroach (40%), and cat dander (23%) was common.42 Future studies should examine the relation among allergen exposure, allergen sensitization, and asthma in random samples of Puerto Rican children in the US mainland and in Puerto Rico.

To our knowledge, this is the first study to compare the prevalence of asthma and asthma hospitalizations of island Puerto Rican children and Puerto Rican children from the mainland United States. Although Puerto Rican children in Puerto Rico had higher SES across multiple measures and were less likely to be born prematurely and to have mothers who smoked during pregnancy, they had significantly higher odds of ever having asthma and of having been hospitalized for asthma. Our findings suggest the need for further study of differences in asthma among Puerto Rican children in these two communities, with emphasis on differences in environmental exposures and the potential contributions of migration, acculturation, and psychosocial stressors in the development of asthma in this high-risk population.

Footnotes

Abbreviations: CI = confidence interval; GED = general equivalency diploma; HS = high school; NHANES III = Third National Health and Nutrition Examination Survey; OR = odds ratio; SES = socioeconomic status; STR = skin test reactivity

This study was supported by the National Institute of Mental Health through grant RO1 MH56401 "Antisocial Behaviors in U.S. and Island Puerto Rican Youth" (The Boricua Youth Study) [H.R.B., Principal Investigator]; the National Center for Minority Health and Health Disparities grant P20 MD000537–01 (to G.J.C.); and by National Heart, Lung, and Blood Institute grants 5 T32 HL07424 (to R.T.C.) and HL04370 and HL073373 (to J.C.C.).

None of the authors have received financial support from or have involvement with an organization with any actual or potential financial interest in the subject matter of this article.

Received for publication August 4, 2006. Accepted for publication December 20, 2006.

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