Undiagnosed asthma adds to the burden of asthma and is an especially significant public health concern among urban adolescents. While much is known about individual-level demographic and neighborhood-level factors that characterize those with diagnosed asthma, limited data exist regarding these factors and undiagnosed asthma. This observational study evaluated associations between undiagnosed asthma and individual and neighborhood factors among a large cohort of urban adolescents. We analyzed data from 10,295 New York City adolescents who reported on asthma symptoms and diagnosis; a subset (n = 6220) provided addresses that we were able to geocode into US Census tracts. Multivariable regression models estimated associations between undiagnosed asthma status and individual-level variables. Hierarchical linear modeling estimated associations between undiagnosed asthma status and neighborhood-level variables. Undiagnosed asthma prevalence was 20.2%. Females had higher odds of being undiagnosed (adjusted odds ratio (AOR) = 1.25; 95% confidence interval (CI) = 1.13–1.37). Compared to White, non-Hispanic adolescents, Asian-Americans had higher risk of being undiagnosed (AOR = 1.41; 95% CI = 1.01–1.95); Latinos (AOR = 0.67; 95% CI = 0.45–0.83); and African-Americans/Blacks (AOR = 0.66; 95% CI = 0.52–0.87) had lower risk; Latinos and African-Americans/Blacks did not differ significantly. Living in a neighborhood with a lower concentration of Latinos relative to White non-Latinos was associated with lower risk of being undiagnosed (AOR = 0.66; CI = 0.43–0.95). Living in a neighborhood with health care provider shortages was associated with lower risk of being undiagnosed (AOR = 0.80; 95% CI =0.69–0.93). Public health campaigns to educate adolescents and their caregivers about undiagnosed asthma, as well as education for health care providers to screen adolescent patients for asthma, are warranted.
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Results available from the corresponding author upon request.
Results of models controlling for asthma severity are available from the corresponding author upon request.
AOR and CI from model with Latino as the reference group.
N.H.L.B.I. Guidelines for the Diagnosis and Management of Asthma. Update on Selected Topics: NIH Publication No. 02-5075. NIH: Bethesda; 2002.
O'Byrne PM, Pedersen S, Schatz M, Thoren A, Ekholm E, Carlsson LG, et al. The poorly explored impact of uncontrolled asthma. Chest. 2013;143:511–23.
Black L, Benson V. Tables of summary health statistics for U.S. children: 2016. National Health Interview Survey: 2018. Available from: http://www.cdc.gov/nchs/nhis/SHS/tables.htm. Accessed 2 April 2018
Zahran H, Bailey C, Damon S, Garbe P, Breysse P. Vital signs: asthma in children – United States, 2001-2016. MMWR Morb Mortal Wkly Rep. 2018;67:149–55.
Glick AF, Tomopoulos S, Fierman AH, Trasande L. Disparities in mortality and morbidity in pediatric asthma hospitalizations, 2007 to 2011. Acad Pediatr. 2016;16:430–7.
Akinbami LJ, Moorman JE, Bailey C, Zahran HS, King M, Johnson CA, et al. Trends in asthma prevalence, health care use, and mortality in the United States, 2001-2010. NCHS Data Brief. 2012;94:1–8.
Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in the United States, 1980-2007. Pediatrics. 2009;123(Suppl 3):S131–45.
Zein JG, Erzurum SC. Asthma is different in women. Curr Allergy Asthma Rep. 2015;15:28–8.
Brewer M, Tolbert KR, Denney JT, Osiecki KM, B. M, Lopez K. Does neighborhood social and environmental context impact race/ethnic disparities in childhood asthma? Health Place. 2017;44:86–93.
Keet CA, Matsui EC, McCormack MC, Peng RD. Urban residence, neighborhood poverty, race/ethnicity, and asthma morbidity among children on Medicaid. J Allergy Clin Immunol. 2017;140:822–7.
Liu SY, Pearlman DN. Hospital readmissions for childhood asthma: the role of individual and neighborhood factors. Public Health Rep. 2009;124:65–78.
Gale SL, Magzamen SL, Radke JD, Tager IB. Crime, neighborhood deprivation, and asthma: a GIS approach to define and assess neighborhoods. Spat Spatiotemporal Epidemiol. 2011;2:59–67.
Holt EW, Theall KP, Rabito FA. Individual, housing, and neighborhood correlates of asthma among young urban children. J Urban Health. 2013;90:116–29.
Wright RJ, Subramanian SV, Wright RJ, Subramanian SV. Advancing a multilevel framework for epidemiologic research on asthma disparities. Chest. 2007;132:757S–769S.
Williams DR, Sternthal M, Wright RJ. Social determinants: taking the social context of asthma seriously. Pediatrics. 2009;123(Suppl 3):S174–84.
Coker TR, Kaplan RM, Chung PJ. The association of health insurance and disease impairment with reported asthma prevalence in U.S. children. Health Serv Res. 2012;47:431–45.
Nichols B, Scott L, Jones S, Kwong K, Morphew T, Jones CA. Detection of undiagnosed and poorly controlled asthma in a hospital-based outpatient pediatric primary care clinic using a health risk assessment system. J Asthma. 2009;46:498–505.
van Gent R, van der Ent CK, van Essen-Zandvliet LEM, Rovers MM, Kimpen JLL, de Meer G, et al. No differences in physical activity in (un) diagnosed asthma and healthy controls. Pediatr Pulmonol. 2007;42:1018–23.
Quinn K, Shalowitz MU, Berry CA, Mijanovich T, Wolf RL, Quinn K, et al. Racial and ethnic disparities in diagnosed and possible undiagnosed asthma among public-school children in Chicago. Am J Public Health. 2006;96:1599–603.
Clark BR, Burkett SA, Andridge RR, Buckley TJ. Evidence of high rates of undiagnosed asthma in central Ohio elementary schoolchildren. J Sch Health. 2013;83:896–906.
Joseph CLM, Havstad S, Anderson EW, Brown R, Johnson CC, Clark NM. Effect of asthma intervention on children with undiagnosed asthma. J Pediatr. 2005;146:96–104.
Bruzzese J-M, Kingston S, Sheares BJ, Cespedes A, Sadeghi H, Evans D. Feasibility and preliminary outcomes of a school-based intervention to help inner-city, ethnic minority adolescents with undiagnosed asthma. Patient Educ Couns. 2011;85:290–4.
Redline S, Gruchalla RS, Wolf RL, Yawn BP, Cartar L, Gan V, et al. Development and validation of school-based asthma and allergy screening questionnaires in a 4-city study. Ann Allergy Asthma Immunol. 2004;93:36–48.
Massey DS. The prodigal paradigm returns: ecology comes back to sociology. In: Booth A, Crouter A, editors. Does it Take a Village? Community Effects on Children, Adolescents and Families. Mahwah, NJ: Lawrence Erlbaum Associates; 2001. p. 41–8.
Sampson RJ, Mare RD, Perkins KL. Achieving the middle ground in an age of concentrated extremes: mixed middle-income neighborhoods and emerging adulthood. Ann Am Acad Pol Soc Sci. 2015;660:156–74.
Carpiano RM, Lloyd JE, Hertzman C. Concentrated affluence, concentrated disadvantage, and children's readiness for school: a population-based, multi-level investigation. Soc Sci Med. 2009;69:420–32.
Rudolph AE, Crawford ND, Latkin C, Fowler JH, Fuller CM. Individual and neighborhood correlates of membership in drug using networks with a higher prevalence of HIV in New York City (2006-2009). Ann Epidemiol. 2013;23:267–74.
Krieger N, Waterman PD, Spasojevic J, Li W, Maduro G, Van Wye G. Public health monitoring of privilege and deprivation with the index of concentration at the extremes. Am J Public Health. 2016;106:256–63.
Feldman JM, Waterman PD, Coull BA, Krieger N. Spatial social polarisation: using the Index of Concentration at the Extremes jointly for income and race/ethnicity to analyse risk of hypertension. J Epidemiol Community Health. 2015;69:1199–207.
Krieger N, Feldman JM, Waterman PD, Chen JT, Coull BA, Hemenway D. Local residential segregation matters: stronger association of census tract compared to conventional city-level measures with fatal and non-fatal assaults (total and firearm related), using the Index of Concentration at the Extremes (ICE) for racial, economic, and racialized economic segregation, Massachusetts (US), 1995-2010. J Urban Health. 2017;94:244–58.
Zeiger RS, Schatz M, Dalal AA, Qian L, Chen W, Ngor EW, et al. Utilization and costs of severe uncontrolled asthma in a managed-care setting. J Allergy Clin Immunol Pract. 2016;4:120–129.e123.
Clark NM, Brown R, Joseph CL, Anderson EW, Liu M, Valerio M, et al. Issues in identifying asthma and estimating prevalence in an urban school population. J Clin Epidemiol. 2002;55:870–81.
Almqvist C, Worm M, Leynaert B. Impact of gender on asthma in childhood and adolescence: a GA2LEN review. Allergy. 2008;63:47–57.
Magzamen S, Tager IB. Factors related to undiagnosed asthma in urban adolescents: a multilevel approach. J Adol Health. 2010;46:581–91.
Lee S, Martinez G, Ma GX, Hsu CE, Robinson ES, Bawa J, et al. Barriers to health care access in 13 Asian American communities. Am J Health Behav. 2010;34:21–30.
Kim W, Keefe RH. Barriers to healthcare among Asian Americans. Soc Work Public Health. 2010;25:286–95.
Vong S, Choi RY. Falling through the cracks: models, barriers and future of health care access for Asian Americans. In: Yoo GJ, Lee M-N, Oda AY, editors. Handbook of Asian American Health. New York: Springer; 2013. p. 303–10.
Desai PP, Rivera AT, Backes EM. Latino caregiver coping with children’s chronic health conditions: an integrative literature review. J Pediatr Health Care. 2016;30:108–20.
McGee SA, Claudio L. Nativity as a determinant of health disparities among children. J Immigr Minor Health. 2018;20:517–28.
Javier JR, Wise PH, Mendoza FS. The relationship of immigrant status with access, utilization, and health status for children with asthma. Ambul Pediatr. 2007;7:421–30.
Syed ST, Gerber BS, Sharp LK. Traveling towards disease: transportation barriers to health care access. J Community Health. 2013;38:976–93.
Hussein M, Diez Roux AV, Field RI. Neighborhood socioeconomic status and primary health care: usual points of access and temporal trends in a major US urban area. J Urban Health. 2016;93:1027–45.
Auger KA, Kahn RS, Simmons JM, Huang B, Shah AN, Timmons K, et al. Using address information to identify hardships reported by families of children hospitalized with asthma. Acad Pediatr. 2017;17:79–87.
Baydar N, Kieckhefer G, Joesch JM, Greek A, Kim H. Changes in the health burden of a national sample of children with asthma. Soc Sci Med. 2010;70:321–8.
U.S. Census Bureau. 2010 Census demographic profile summary file -- profile of general population and housing characteristics: 2010. 2010 Census Demographic Profile Summary File -- Profile of General Population and Housing Characteristics: 2010 Prepared by the U.S. Census Bureau, 2011.
The authors would like to thanks Drs. Tonda Hughes and David Evans for their expert review of our manuscript.
The National Institutes of Health (R01HL089493 to JMB) supported this work. The sponsor had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of this manuscript; and in the decision to submit the manuscript for publication.
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Jean-Marie Bruzzese and Sharon Kingston are co-first authors.
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Bruzzese, JM., Kingston, S., Falletta, K.A. et al. Individual and Neighborhood Factors Associated with Undiagnosed Asthma in a Large Cohort of Urban Adolescents. J Urban Health 96, 252–261 (2019). https://doi.org/10.1007/s11524-018-00340-2