Description
Starting with your introduction, I would incorporate a definition of asthma and a description of symptoms. Are there different sub-types that should be discussed here? What are the consequences/implications of asthma? I would also report general prevalence of asthma, and any changes in prevalence over the last decade or so (if notable). After establishing this background, then I would get in to what you have here to establish the presence of a disparity that is worth exploring with a literature review. I am also a bit confused by your first CDC citation- is that the title of the web page? You may be able to truncate this to (CDC, 2019). I would also consider revising your research question for clarity- something along the lines of ‘what factors contribute to the elevated prevalence of asthma in adolescents living in urban environments in the United States?’ (lung function is a very broad term, and I think specifying your interest in asthma here will help remove any confusion for your reader).For your methods, with 10 searches you should absolutely consider a table to keep track of these and avoid heavy repetition in your methods section. Even if you have identical inclusion/exclusion criteria for every search this would be a lot to cover long-form. You are also missing some key details here. You should report the size of the pool of results with just search terms, and after applying your filters for publication date and peer reviewed literature. You need to report how many articles you ultimately included in your paper from each search, and what your process was for sorting through the articles in your final results pool to identify those articles you wanted to include. You may have looked at every title/abstract and then selected articles to read further from there- whatever your process was you need to report it. See the examples on ELC for guidance on structuring a methods table/how to write up and report your search strategy. As for your results, you need to get some thematic organization going here. Looking through your citations I see several that address outdoor/traffic-related air pollution- this would be a good theme. You also talk about housing-related exposures (pestilence, indoor smoke), another good potential theme. For your third theme, you might consider looking at differences in how asthma is treated in urban settings, or identify some other common thread as you read more literature. Regardless of what themes you land on, you should organize your presentation of results in this way to help with readability and to ensure you are not repeating yourself over the course of your results section. You have a lot going on in your discussion. Typically this section is structured as a brief synthesis of your results (do not reuse citations, and do not restate what you have already said in the results), followed by a discussion of the limitations of your review and then some coverage of solutions to the issues you highlighted previously. Is a policy-level change the most appropriate course of action? Are any of those risk factors you identified manageable through education, or are there specific programs dedicated to reducing the presence of those risk factors? See what is being done in this field and what might help improve this disparity.
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HPRB 5010
Literature Review Outline
INTRODUCTION
Health Problem
• A significant impact of asthma has been recognized for some time by epidemiologists and
clinical researchers in urban areas with high poverty rates and significant minority
populations. Increasing hospitalizations and deaths from severe asthma episodes
emphasizes this (CDC – Asthma – Interventions – Case Studies – Inner City Asthma Research Base, 2019).
• There is an association between urbanization and asthma prevalence, which may be
attributed to multiple lifestyle factors. Asthma is also thought to be increased by exposure
to various environmental allergens and irritants, including indoor and outdoor air
pollutants, house dust mites, molds, and occupational exposures to chemicals, fumes, or
dust (World Health Organization, 2023).
Target Population
• Children under the age of 21
Research Question
• What impact does the environment in the United States have on young children’s lung
function in inner-city neighborhoods?
METHODS
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A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*environment OR home environment*) AND children
AND lung function AND (*inner city OR city OR urban OR cities*)
o The study selection criteria were that they had to be published within the last 10
year, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 340 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
A search was conducted on Medline with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: environment AND (*children OR kids OR youth OR
child*) AND (*pulmonary function OR cardiopulmonary function OR lung
function OR respiratory function*) AND (*inner city OR city OR urban OR
cities*)
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
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o This search yielded 164 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*children OR adolescents OR youth OR child OR
teenager*) AND asthma treatment AND (*inner city OR city OR urban OR
cities*)
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 1,925 results. More detail will be added to the methods
section once all the chosen articles are finalized for this literature review.
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*asthma in children OR pediatric asthma OR asthma
children OR pediatric asthma*) AND (*treatment OR intervention OR therapy*)
AND (*low-income OR poverty OR low socioeconomic status*) AND treatment
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 436 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*asthma in children OR pediatric asthma OR asthma
children OR pediatric asthma*) AND healthcare access AND social determinants
of health
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 85 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*asthma in children OR pediatric asthma OR asthma
children OR pediatric asthma*) AND treatment in inner-cities
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 175 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
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A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*asthma in children OR pediatric asthma OR asthma
children OR pediatric asthma*) AND environment AND (*united states or
america or usa or u.s*) AND (*low-income or poverty or low socioeconomic
status*)
o This search yielded 182 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 175 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*asthma in children OR pediatric asthma OR asthma
children OR pediatric asthma*) AND traffic AND (*united states or america or
usa or u.s*) AND (*inner city or city or urban or cities*)
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: (*asthma in children OR pediatric asthma OR asthma
children OR pediatric asthma*) AND environmental factors AND (*united states
or america or usa or u.s*) AND (*inner city or city or urban or cities*)
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 571 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
A search was conducted on all providers with UGA’s database system for peer reviewed
articles from 2014-2024
o The search terms were: exacerbation of asthma AND (*children or pediatric or
pediatric or kids or child*) AND (*inner city or city or urban or cities*) AND
environmental AND *(united states or america or usa or u.s*)
o The study selection criteria were that they had to be published within the last 10
years, peer reviewed academic journals, and included information that is relevant
to the primary risk factors of environmental factors associated with lung function
in children who live in inner-city neighborhoods.
o This search yielded 180 results. More detail will be added to the methods section
once all the chosen articles are finalized for this literature review.
RESULTS
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It is more common for African American and Latino children to have asthma due to low
income and housing issues that may be to expensive to fix. As a part of a program for
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pediatric asthma in the low-income, urban community, parents participated in a program
to better care for their children and gain knowledge for managing their asthma (Janevic et
al., 2017).
People who are at a disadvantage believe that they will be retaliated against if they seek
assistance from landlords, employers, and legal resources. This leads to the children in
the home having to suffer from exposures such as mice, mold, roaches, and water leaks.
Having a disparity creates a boulder for access to care and leads to children being more
susceptible to suffering from asthma (Harris et al., 2018).
Children in inner cities should receive asthma-focused visits outside of routine health
maintenance visits and spirometry testing guidelines should be adopted more frequently
in order to improve asthma management. A separate asthma visit provided by an asthma
program onsite received guideline-level asthma care for inner-city asthmatic
children. Asthma has hospitalized 7.7% of children in this study, but 90% of children
meet the criteria for uncontrolled asthma. The severity of asthma in inner-city
communities often results in children visiting the ER and missing school days due to the
severity of the condition (Warman & Silver, 2016).
Tree pollen increases the risk of asthma exacerbations in Philadelphia children. Asthma
exacerbation visits to the emergency department were statistically significant after
exposure to pollen. There was a 1 or 2 day lag when referring to oak trees, which had a
stronger effect (De Roos et al., 2020).
When exposure to traffic related air pollution, specifically diesel exhaust, is increased for
6 hours in under resourced neighborhoods, FeNO levels are higher. Air pollution from
traffic has rapid effects on the lungs (Ji et al., 2024).
The weather, dust, and exercise in low-income renters’ homes have been found to worsen
asthma symptoms. Additionally, less than half of the participants in this study selected
roaches, tobacco smoke, and mold. Among participants, one-third were unsure about how
often furnace filters were changed, and a quarter said never. According to 37% of
participants, water leaks mainly occur in the bathrooms, which eventually lead to mold
growth. As a result of their lack of money and power, low-income renters are vulnerable
to asthma triggers in their homes (Liu et al., 2022).
Compared to children living in rural areas, children living in urban areas had twice the
number of asthma cases due to traffic-related air pollution. Furthermore, children living
in households with a lower median income had a higher percentage of asthma patients
compared to children living in households with a higher median income. Asthma was
more common among children in areas with lower incomes and high traffic density
(Alotaibi et al., 2019).
Following elevated concentrations of pollutants, school-age children are at a small
increased risk of developing asthma. A strong confounder of observed air pollutantasthma hospital admissions association is pollen, but admissions for respiratory infections
do not appear to be a confounder (Goodman, Loftus, Liu, & Zu, 2017).
Second hand smoke exposure has no impact of asthma symptoms at 12 months in a
sample of low-income minority children with poorly controlled asthma (Butz et al.,
2019).
Children’s exposure to a non-tailpipe emissions indicator, such as barium, showed a
positive association with FeNO (8.9% increase with an increase in the interquartile range
(IQR), 95% confidence interval (CI): 2.8, 15.4) as well as industrial emissions indicators
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(7.6% increase for a vanadium IQR increase, 95% confidence interval (CI): 0.1, 15.8). At
a 1-day lag period, FeNO levels in other metals were also higher: 10.3 % for aluminum
(95 % CI: 4.2, 16.6) and 7.5 % for iron (95 % CI: 1.5, 13.9) (Godri Pollitt et al., 2016).
DISCUSSION
•
There are significant findings regarding the impact of the environment on the lung
function of young children in inner-city neighborhoods. Asthma-related issues are
disproportionately prevalent in low-income urban communities, especially those with
large minority populations. Education programs show promise in improving asthma
treatment for children. Individuals with disadvantages have difficulty seeking assistance
for housing-related issues, which increases their exposure to asthma triggers, such as
mold and pests, which makes them more susceptible to an asthma attack. Increasing
asthma management among inner-city children requires asthma-focused visits as well as
guidelines for spirometry testing. It is important to reduce asthma exacerbations by
reducing environmental factors such as tree pollen and traffic-related air pollution. The
weather, dust, and lack of maintenance in the homes of low-income renters make them
particularly susceptible to asthma triggers. Asthma is more likely to affect children living
in urban areas with lower median incomes and high traffic density. Among low-income
minority children with poorly controlled asthma, secondhand smoke exposure does not
significantly influence asthma symptoms.
Limitations
• Second-hand Smoke Exposure
o Patterns based on caregiver report, introducing potential for recall or social
desirability bias.
o Not all sources assessed, including public places, relatives, or social network
homes.
o Cotinine levels reflect snapshot of recent exposure, possibly explaining lack of
association with symptoms.
o Housing type not ascertained, potentially overestimating exposure if multi-unit
with shared ventilation.
• Study Design and Bias
o Non-experimental design challenges attribution of observed improvements to
intervention.
o Social desirability bias may influence data collected from parents.
o Use of newly-developed measures hinders comparison to prior studies.
o Natural improvement over time in pediatric asthma symptoms raises uncertainty
without intervention.
• Asthma and Pollen Exposure
o Lack of information on allergic sensitization limits understanding of pollen
effects.
o Absence of data on indoor smoking, a known asthma trigger.
o Potential bias from case-crossover design for estimating pollen effects.
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o Measurement error in pollen exposure data may lead to biased exposure
misclassification.
o Association with grass pollen limited to children under 2 years old, raising
diagnostic questions
Asthma Trigger Management
o Lack of resources, power, and knowledge among low-income renters hinders asthma
trigger management.
o Systemic issues like lease restrictions and building hazards complicate trigger
management.
FeNO Measurement and Trace Metals
o FeNO measurement limitations as subclinical biomarker.
o Issues with personal sampler flow, metal measurement errors, and low PM mass
loading.
o Recruitment and trace metal measurement limitations lead to small sample size.
o Interpretation of personal trace metal concentrations may be inaccurate.
Retrospective Chart Review
o Limited generalizability from single clinical site serving low-income population.
o Potential bias from referral-enriched sample and incomplete spirometry testing.
o Disease severity modification by controller medications and variation over time.
o – Clinical histories consistent with Bronchopulmonary Dysplasia may affect
interpretation.
Barriers in Health Access
o Inability to question landlords or employers limits validation of experiences.
o Data saturation with small sample limits generalizability.
o Purposeful sampling may not encompass all barriers faced by patients.
o Exclusion of smokers affects diagnosis accuracy.
Ecological Study and Pollutants
o Central site monitor reliance leads to exposure measurement error.
o Geographic heterogeneity in pollen concentrations complicates exposure
estimation.
o Confounding by time-varying factors and pollen, with small effect estimates for
certain pollutants.
o Daily healthcare encounter counts may not represent true exposure patterns.
o Complex confounding by pollen and analytical uncertainties in estimating
socioeconomic status.
REFERENCES
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Alotaibi, R., Bechle, M., Marshall, J. D., Ramani, T., Zietsman, J., Nieuwenhuijsen, M. J., &
Khreis, H. (2019). Traffic related air pollution and the burden of childhood asthma in the
contiguous United States in 2000 and 2010. Environment International, 127, 858-867.
doi:10.1016/j.envint.2019.03.041
Butz, A. M., Tsoukleris, M., Elizabeth Bollinger, M., Jassal, M., Bellin, M. H., Kub, J., . . .
Thompson, R. E. (2019). Association between second hand smoke (SHS) exposure and
caregiver stress in children with poorly controlled asthma. Journal of Asthma, 56(9), 915926. doi:10.1080/02770903.2018.1509989
Centers for Disease Control and Prevention. (2009, April 24). CDC – asthma – interventions – case
studies – inner city asthma – research base. Centers for Disease Control and Prevention.
https://www.cdc.gov/asthma/interventions/inner_city_asthma_researchbase.htm#:~:te
xt=Epidemiologists%20and%20clinical%20researchers%20have,lead%20to%20hospitaliz
ation%20or%20death
De Roos, A. J., Kenyon, C. C., Zhao, Y., Moore, K., Melly, S., Hubbard, R. A., . . . Schinasi, L.
H. (2020). Ambient daily pollen levels in association with asthma exacerbation among
children in Philadelphia, Pennsylvania. Environment International, 145, N.PAG-N.PAG.
doi:10.1016/j.envint.2020.106138
Godri Pollitt, K. J., Maikawa, C. L., Wheeler, A. J., Weichenthal, S., Dobbin, N. A., Ling, L., . . .
Liu, L. (2016). Trace metal exposure is associated with increased exhaled nitric oxide in
asthmatic children. Environmental Health: A Global Access Science Source, 15, 1-11.
doi:10.1186/s12940-016-0173-5
Goodman, J. E., Loftus, C. T., Liu, X., & Zu, K. (2017). Impact of respiratory infections, outdoor
pollen, and socioeconomic status on associations between air pollutants and pediatric
asthma hospital admissions. PLoS ONE, 12(7), 1-15. doi:10.1371/journal.pone.0180522
Harris, D. A., Mainardi, A., Iyamu, O., Rosenthal, M. S., Bruce, R. D., Pisani, M. A., & Redlich,
C. A. (2018). Improving the asthma disparity gap with legal advocacy? A qualitative
study of patient-identified challenges to improve social and environmental factors that
contribute to poorly controlled asthma. Journal of Asthma, 55(8), 924-932.
doi:10.1080/02770903.2017.1373393
Janevic, M. R., Baptist, A. P., Bryant-Stephens, T., Lara, M., Persky, V., Ramos-Valencia, G., . . .
Malveaux, F. J. (2017). Effects of pediatric asthma care coordination in underserved
communities on parent perceptions of care and asthma-management confidence. Journal
of Asthma, 54(5), 514-519. doi:10.1080/02770903.2016.1242136
Ji, N., Baptista, A., Yu, C. H., Cepeda, C., Green, F., Greenberg, M., . . . Laumbach, R. J. (2024).
Traffic-related air pollution, chronic stress, and changes in exhaled nitric oxide and lung
function among a panel of children with asthma living in an underresourced community.
Science of the Total Environment, 912. doi:10.1016/j.scitotenv.2023.168984
Liu, M., Chung, J. E., Robinson, B., Taylor, L., Andrewn, R. A., & Li, J. (2022). A home visit
program for low-income African American children with asthma: Caregivers’ perception
of asthma triggers and a gap in action. Journal of Pediatric Nursing, 67, e79-e84.
doi:10.1016/j.pedn.2022.09.006
Warman, K., & Silver, E. (2016). A primary care-based asthma programimproves recognition and
treatment of persistent asthma in inner-city children compared to routine care. Journal of
Asthma, 53(9), 930-937. doi:10.3109/02770903.2016.1161051
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World Health Organization. (2023, May 4). Asthma. WHO; World Health Organization.
https://www.who.int/news-room/fact-sheets/detail/asthma
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