Assessing Indoor Environmental Control Practices by Race/Ethnicity Among Children With Asthma in 14 US States and Puerto Rico, 2013–2014

Faye M. Rozwadowski, MD; Ginger L. Chew, ScD; Hatice S. Zahran, MD, MPH; Melissa L. Santorelli, PhD, MPH


Prev Chronic Dis. 2019;16(12):E166 

In This Article

Abstract and Introduction


Introduction: In the United States, children in Puerto Rico and non-Hispanic black children in the mainland US have a higher burden of asthma than non-Hispanic white children in the mainland US. We examined indoor environmental control (IEC) practices that reduce asthma triggers, by race/ethnicity among children in the mainland US and Puerto Rico.

Methods: We used 2013 and 2014 data from the Behavioral Risk Factor Surveillance System Asthma Call-back Survey Child Questionnaire from 14 states and Puerto Rico to measure the association between race/ethnicity and IEC practices, adjusting for sociodemographic covariates, among children identified as ever receiving an asthma diagnosis. Racial/ethnic groups were compared in 14 US states using aggregated data. Separate analyses compared IEC practices for children diagnosed with asthma in Puerto Rico with children of all races/ethnicities diagnosed with asthma in 14 states.

Results: Among households in 14 US states that had a child with asthma, non-Hispanic black children were more likely than non-Hispanic white children to use an air purifier (36.8% vs 25.2%; adjusted odds ratio [aOR] = 2.0; 95% confidence interval [CI], 1.3–3.2) and avoid pets in the bedroom (87.9% vs 58.3%; aOR = 4.5; 95% CI, 2.3–8.8). Children in Puerto Rico were more likely than children in 14 states to use dust mite–impermeable pillow covers (53.7% vs 36.4%; aOR = 3.6; 95% CI, 1.8–7.1) and mattress encasements (60.3% vs 30.3%; aOR = 2.4; 95% CI, 1.2–4.8).

Conclusion: IEC practices such as using air purifiers, pillow covers, mattress encasements, and avoiding pets in the bedroom vary by race/ethnicity among children with asthma. These findings show that vulnerable populations are using IEC practices, but asthma prevention and control measures should continue to be assessed.


Asthma is the leading chronic disease among children in the United States, the top reason for missed school days, and the third leading cause of pediatric hospitalizations.[1] Racial/ethnic disparities exist in childhood asthma prevalence. In the United States, non-Hispanic black children are twice as likely as non-Hispanic white children to have received a diagnosis of asthma, 2 to 3 times as likely to be hospitalized for asthma, and 4 times as likely to die from asthma.[2]

Puerto Rican children are an additional vulnerable population who experience the highest prevalence of asthma (11%) compared with non-Hispanic black (7.7%) and non-Hispanic white children (5.3%) in the US mainland. In Puerto Rico, 32% of children have received a diagnosis of asthma, compared with 12.6% of children in the US mainland.[3] The lifetime odds of having received an asthma diagnosis among Puerto Rico island resident children born to Puerto Rico island residents is 2.5 times higher than United States mainland-born non-Hispanic white children with United States mainland-born parents.[4]

The National Heart, Lung, and Blood Institute's (NHLBI's) Guidelines for the Diagnosis and Management of Asthma outline multiple indoor environmental control (IEC) practices to reduce asthma triggers. IEC practices in households of children with asthma have been shown to reduce asthma symptoms.[5] A common asthma trigger, dust mites and their allergens, can be effectively controlled by washing bedding weekly in hot water, using dust mite–impermeable pillow covers and mattress encasements, and reducing household humidity levels. Preventing smoking in the home and keeping pets out of children's bedrooms are additional recommended IEC practices.

Understanding racial/ethnic differences in the use of environmental control measures can help implement evidence-based interventions. The only comparable study to our assessment comes from the 2003 National Asthma Survey. This survey suggested that the use of mattress encasements and dust mite–impermeable pillow encasements is lower among non-Hispanic black and Hispanic children with asthma, compared with non-Hispanic white children with asthma. Nonetheless, the sampling frame included only 4 states and excluded participants with cellular telephones and residents of Puerto Rico.[6] In addition, IEC practices were not examined separately among any of the subsets of Hispanic (eg, Puerto Rican or Mexican ethnicity) children in the reference study, which is a limitation given the disproportionate burden of asthma for children in Puerto Rico.

We assessed disparities in IEC practices by race/ethnicity among children with asthma using a large and inclusive sample from the Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey (ACBS).