Asthma diagnosis among children along an urban-rural gradient

Objective: Studies have reported lower asthma prevalence in rural compared to urban areas. While environmental factors have mostly been implicated for these differences, the lower asthma prevalence could also be linked to asthma under-diagnosis in rural children. We investigate if rural children experience under-diagnosis of asthma more compared to urban children. Methods: In 2013, we conducted a cross-sectional survey of schoolchildren across an urban-rural gradient in Saskatchewan, Canada. The participants formed sampling frame for future studies. In 2015, we approached those who gave consent in 2013 for further testing, repeated the survey, and conducted clinical testing. Based on survey responses, children were classified into no asthma, at-risk-for-asthma, and diagnosed asthma. We then classified asthma status as either no asthma or probable asthma based on a validated asthma algorithm. Results: The study population of 335 schoolchildren (aged 7-17 years) comprised of 73.4% from large urban, 13.7% from small urban, and 12.8% from rural areas. Proportion with report of physician-diagnosed asthma was 28.5% (Large urban), 34.8% (Small urban), and 20.9% (Rural). Mean percent predicted FEV1 and FEF25%-75% were lower in rural compared to small urban and large urban children (p < 0.05). Among those not classified as with diagnosed asthma by the survey, the algorithm further identified presence of asthma in 5.5% large urban, 8.1% small urban, and 18.8% rural children (p = 0.03). Conclusion: The study revealed evidence of asthma underdiagnosis in rural areas and further supports the use of objective measures in addition to symptoms history when investigating asthma across urban-rural gradients.