This cross-sectional survey was conducted to understand parents' perceptions regarding air pollution and its effect on children's respiratory health in Nanchang, China, to offer baseline information useful to the government of the People's Republic of China. Data collected from 1,056 residents (response rate = 93.7%) was analyzed using descriptive analysis, chi-square test, nonparametric rank-sum test, Spearman rank correlation coefficient, and linear trend test. The results showed that most parents would worry more about their children's health if air quality became worse, especially in families with high education and income. The top three respiratory conditions associated with poor air quality among children were cough (90.5%), upper respiratory infection (72.9%), and bronchitis (47.2%). Parents believed motor vehicle emissions (95.9%), secondhand smoke (95.4%), and dust (92.9%) to be the risk factors largely responsible for respiratory illnesses among children. Furthermore, most respondents supported government intervention to improve air quality with several suggestions: controlling industrial pollution (69.9%), increasing public transportation and reducing private cars (51.0%), and controlling and reducing waste incineration (45.6%).
People in China are becoming more aware of the quality of their life, opting to live in a comfortable environment and to lead a healthy lifestyle. This shift is due to the rapidly developing economy, progress of science and technology, and the improvement of people's living standards (Zhang, Yuan, & Zhao, 2011). The rapid urbanization and population density surge in parts of China, however, have released large amounts of harmful pollutants into the atmosphere, seriously threatening people's health. Particulate matter less than 10 micrometers in diameter ([PM.sub.10]), sulfur dioxide (S[O.sub.2]), and nitrogen oxides (N[O.sub.x]) are the main air pollutants caused by the manufacturing industry and transportation. Emission of S[O.sub.2] is primarily from industry and daily activities such as coal burning by residents (Ministry of Environmental Protection of the People's Republic of China [MEP], 2013). Coal burning has been reduced to 20.4 million tons, a 3.5% reduction compared with 2012. In China in 2013, N[O.sub.x] emissions, which are released primarily by industrial and motor vehicle exhaust, were reduced to 22.3 million tons, representing a 4.7% reduction compared with 2012 (MEP, 2013).
These improvements notwithstanding, the city's ambient air quality status is still not cause to be optimistic. Air quality remains a health risk in most of the major cities (World Health Organization [WHO], 2016). According to the Ministry of Environmental Protection of the People's Republic of China (MEP), a surveillance study was conducted in 2013 among 74 cities in China, including Beijing, Tianjin, and cities along the Yangtze River and Pearl River regions. MEP assessed the effects of the implementation of new ambient air quality standards with modified indication values of S[O.sub.2], N[O.sub.2], [PM.sub.10], [PM.sub.2,5], carbon monoxide (CO), and ozone ([O.sub.3]) (MEP, 2012). MEP reported that only three cities--Haikou, Zhoushan, and Lhasa--met the air quality standards, accounting for 4.1% of cities assessed, while the other 71 cities (95.9%) were above recommended pollutant levels (MEP, 2013).
Nanchang, the capital of Jiangxi province and the 25th largest city in China, is adjacent to the three most dynamic economic developmental regions: the Yangtze River delta, the Pearl River delta, and MinDongNan triangle. Nanchang's economy relies mainly on industry, particularly construction, making it subject to air pollution with particulate matter and other pollutants (National Bureau of Statistics of the People's Republic of China, 2014).
One study found that the higher concentration of [PM.sub.10] was largely due to city construction dust and vehicle exhaust emission, which was a result of increased motor vehicles and more construction sites for city buildings, as well as subway development in the past years (Zou et al., 2015). In Nanchang, 7 of 40 days (<18%) measured between April and May 2014 did not meet the ambient air quality standards (Nanchang City Environmental Protection Bureau, 2014).
Air quality is closely related to the overall competitiveness of a city, directly affecting residents' health and quality of life, which impacts the investment environment. The World Health Organization (WHO) reported that outdoor air pollution in both urban and rural areas caused approximately 3.7 million premature deaths worldwide in 2012; furthermore, 88% of deaths occurred in low-and middle-income level countries, primarily located in the western Pacific and Southeast Asia (WHO, 2016).
Indoor air pollution is a problem, too. Approximately 4.3 million people die each year from indoor air pollution from causes such as inefficient cooking and heating practices (cooking and heating their homes with solid fuels such as wood, charcoal, coal, dung, crop wastes) and smoking in and around the home (WHO, 2014).
Other reports have indicated air pollution is associated with a broad range of health risks (Collins, Parsons, & Zinyemba, 2014) and might potentially play a role in elevated incidence rates of breast cancer in urban areas (Garcia et al., 2014). This issue has attracted close attention from the government and residents of the People's Republic of China.
The serious effects of poor air quality on the sensitive respiratory systems of children are much more apparent than in adults. A study by Liu and Zhang (2009) found major effects of air pollution on children's lung function. The levels of total suspended particles and S[O.sub.2] in ambient air correlated with damage to the big airway function of children, while N[O.sub.x] mainly affected the small airway function. Another study revealed a positive correlation of the exposure to [PM.sub.2.5] and [PM.sub.10] with the incidence of childhood respiratory illnesses (Liu, Li, Hu & Sun, 2014). Studies on the effects of air pollution on respiratory health have frequently been conducted in many parts of the world (Beatty & Shimshack, 2014; Kong, He, Xu, Xu, & Guo, 2001).
Additionally, there have been several studies on air quality including environmental air quality standards and management policies, the air pollution index variation characteristics and influence factors, and the effects of air quality on health (Liao, Xu, & Zhang, 2010; Liu et al., 2005; Wang et al., 2013).
Little investigation, however, has been conducted to examine the public's perceptions regarding air pollution and its effect on children's respiratory health in China. This study, through interviews with Nanchang parents of both healthy and sick children, aimed to understand parents' perceptions of Nanchang air quality and the potential effects of air pollution on their children's respiratory health. In addition, this study was designed to obtain baseline information useful to the Nanchang government in its attempt to improve air quality and protect children's respiratory health in the future.
Materials and Methods
Participants selected for this study were parents, including caregivers and caretakers, who had at least one child between the ages of 2-10 years. Parents were interviewed through a face-to-face method with trained interviewers. A total of 1,056 survey questionnaires were collected. Among these participants, 526 were parents with healthy children from a Nanchang city kindergarten, a primary school of Nanchang, and the Nanchang Center for Disease Control and Prevention (NCDC). The other 530 participants were parents who had sick children waiting to see medical doctors in Jiangxi Children's Hospital in Nanchang. The number of valid responses was 989 (response rate = 93.7%) and the basic demographic information about these respondents is summarized in Table 1.
To ensure the reliability and validity of this survey, the questionnaires used were de signed by public health experts and refined based on our 2013 study (Zhang et al., 2014). Our 2013 study was carried out in four sites, including two NCDC locations, Jiangxi Children's Hospital, and a local kindergarten. Additionally, the study team members received training on questionnaire details and survey techniques. Pilot presurvey tests were performed before the survey was conducted.
The questionnaires covered five major aspects: 1) general demographic characteristics of the interviewees (age, gender, educational level, place of residence, travel experiences, and annual household income); 2) children's health conditions (age, overall health, respiratory diseases, symptoms in children when air quality was poor); 3) parents' concerns about the air quality in Nanchang; 4) parents' understanding of the linkage between air quality and children's health problems (impact on children's respiratory system, factors aggravating symptoms in children, how worried parents were about respiratory health problems caused by air pollution); and 5) parents' attitudes towards the government's policies. All participants were assessed through confidential face-to-face interviews.
All data were analyzed with SPSS version 17.0. General demographic characteristics of the interviewees and health condition of the children were described with descriptive statistics. Chi-square tests compared the differences of parents' perception of air quality and the cognitive relationship of air quality with parents' perception about children's health according to general demographic characteristics of the interviewees. The general chisquare analysis was run on frequency distribution data. A nonparametric rank-sum test was used to order classification data values status. Linear trend tests and Spearman rank correlation coefficients were used to analyze the bidirectional orderly and different properties contingency table data. The level of a was set at 0.05.
Health conditions of healthy children from a Nanchang city kindergarten, a primary school of Nanchang, and NCDC locations were much better than sick children from Jiangxi Children's Hospital (p < .001), matching assumptions that children selected from the kindergarten would be much healthier than those from the hospital site. Most participants generally believed that their child's overall health was good (69.2%) (Table 2). Data indicated that parents' perception of their children's health was significantly affected by location of their residence, showing that parents from Nanchang city considered their children to be healthier than those from the countryside (p = .004). Parents' age was shown to be a significant factor affecting their perception of children's health. Older parents had higher rates of believing their children to be in good health (p < .001). Our data showed that travel experience nationally and/or internationally was also a significant factor affecting parents' perception of their children's health (Table 2).
Based on parent recall, cough, upper respiratory tract infection, and bronchitis were the top three common respiratory conditions among children in Nanchang (Table 3). The rates of coughing in children significantly increased, 90.5% versus 82.8%, when compared with 2013 ([chi square] = 113.786, p < .001). Although 72.9% of children suffered from upper respiratory tract infection, a decrease is shown when compared with the 2013 study result of 89.5% ([chi square] = 138.106, p < .001). The frequency of bronchitis, however, was 47.2%, which was significantly greater than the results of our 2013 study of 29.3% ([chi square] = 98.889, p < .001) (Zhang et al., 2014). The data in Table 4 show the Spearman rank correlation coefficient ([r.sub.s]) between perceptions and respiratory diseases in children; that is, parents' perception about the general health condition of their child was in accordance with rates of allergies ([r.sub.s] = 0.095, p = .003), bronchitis ([r.sub.s] = 0.173, p < .001), upper respiratory infection ([r.sub.s] = 0.218, p < .001), and coughing ([r.sub.s] = 0.204, p < .001) (Table 4).
As shown in Table 5, the data revealed a positive correlation between concerns regarding children's health and parents' education level, place of residence, annual household income, and travel experience. Parents with a higher educational level (a college degree or higher) and/or higher annual income ([greater than or equal to] 75,000 Chinese yuan) worried more about their children's health ([r.sub.s] = 0.182, p < .001), ([r.sub.s] = 0.123, p < .001), respectively. Parents who live in the city or have previous travel experience were also more likely to be more concerned about their children's health (Table 5).
When air quality was poor, the top three common symptoms reported by parents with affected children included dry throat pain (60.1%), sneezing (49.5%), and coughing (37.7%) (Figure 1). As shown in Figure 2, the majority of parents believed that their children's respiratory health was affected by polluted air, mainly from motor vehicle emissions (95.9%), secondhand smoking (95.4%), and dust (92.9%). As indicated in Table 6, bronchitis was associated with high levels of dust, vehicle exhaust emissions, and secondhand smoking, which were some of the factors parents considered as worsening their children's respiratory symptoms. While upper respiratory tract infections were associated with dust and motor vehicle exhaust emissions, coughs were associated only with dust.
In view of the current air quality in Nanchang and parents' perceived impact of air quality on children's health, most parents expressed their strong support to local government to improve air quality. Participants were also asked to give their suggestions on measures to improve air quality. The top three suggestions were to control and reduce air pollution from industrial facilities (69.9%), increase public transportation and reduce private cars (51.0%), and control and reduce waste incineration (45.6%). Other suggestions for local governments to consider included reducing cigarette smoke (30.3%), implementing a nationwide effort to control air pollution (29.7%), increasing solar and green energy options (25.9%), and improving urban housing construction (25.6%).
With the rapid growth of the Chinese economy, many cities in China are facing a concerning situation of multiple pollutant emissions and poor air quality. Due to elevated energy consumption, electricity generation, and motor vehicle use, increased pollutants are severely and adversely affecting the quality of life of residents (Wang & Hao, 2012). Recent studies on air quality and pollution types have indicated that the pollution in the atmosphere in Nanchang is complex, with several main pollutants including [PM.sub.10], S[O.sub.2], and N[O.sub.x] attributed to motor vehicle exhaust emissions (Zhuang et al., 2014).
The air pollution issue has caught the attention of local government and residents. Risk perception means individuals' feeling and understanding of different objective risk outside (Slovic, 1987). Humans perceive and act on risk in two fundamental ways. Risk as feelings refers to individuals' instinctive and intuitive reactions to danger. Risk as analysis brings logic, reason, and scientific deliberation to bear on risk management (Slovic & Peters, 2006). The public's perception of risk guides their behavior to a large degree, impacting effectiveness of the risk management policy and implementation. Air pollution risk management has become one of the key tasks for the government. Residents' understanding and cooperation (i.e., risk perception) benefit risk management of air pollution (Zhu & Xu, 2014).
Studies on the public's air risk perception started in the 1950s and 1960s in the U.S. with quantitative methods (Johnson et al., 1972; Smith, Schueneman, & Zeidberg, 1964); then in the 1990s, researchers started using qualitative methods on air pollutionrelated perceptions (Saksena, 2011). More re cent studies on air pollution perception have focused on improvement of risk communication (Egondi et al., 2013; Nikolopoulou, Kleissl, Linden, & Lykoudis, 2011) and on factors that can influence perceptions (Johnson, 2012). Part of the aim of these studies was to bridge the gap between scientific research and public awareness.
Our study showed that, as expected, the general health status of children from the Nanchang city kindergarten, the Nanchang primary school, and NCDC sites was better than the health status of children enrolled from Jiangxi Children's Hospital. Researchers expected that children selected from the kindergarten would be much healthier than those from the hospital site. Almost all parents believed that their children's overall health was good, especially those parents living in the city (p = .004). The health status of children in rural areas of Nanchang was reported to be worse than children in the city because rural children were more likely to be subjected to several risk factors, including direct or indirect contact with dust, infectious bacteria, and disease-carrying insects (Pluhar, Piko, Kovacs, & Uzzoli, 2009).
Among the respondents, older parents considered their children to be in better health, with a linear trend value of 22.253 (p < .001). One explanation for this observation is that older parents have greater access to child care, which has been shown keep children healthier. As stated previously, we uncovered a positive correlation between children's health status and parents' travel experience. As travel experience is closely related to household income status, parents with higher income have more means to travel. Those with more resources might also be able to focus more on leading a healthier lifestyle. Our results suggest that families' socioeconomic status has much to do with health status. Thus, findings from this study suggest that education and healthy habits should be promoted, especially in the rural areas, specifically targeting parents ages 20-40 (Neidell, 2004).
The top three respiratory conditions found in children in Nanchang, China, were cough, upper respiratory tract infection, and bronchitis. Cough and bronchitis were particularly prevalent, reaching 90.5% and 47.2%, respectively, indicating that children are suffering more from cough or bronchitis as compared with previous years (Zhang et al., 2014). This alarming increase might be a serious risk to children from long-term cumulative exposure to polluted air in Nanchang. The consistency of parents' perception about general health status and respiratory conditions (allergies, bronchitis, upper respiratory infection, and coughing) in children indicated that parents' perceptions seemed to be credible.
Parents have different levels of concern about the effects of worsening air pollution on their children's respiratory health. Such differences depend on educational levels, place of residence, household income levels, and travel experience. In particular, education and household income levels were positively correlated with the degree of parental concern.
This result is in agreement with a study showing that parents with higher educational levels and higher household income pay more attention to air quality, seek a better quality of life, and worry more about their children's health (Zhang et al., 2014). Another study revealed that the health effects of air pollution could also vary depending on socioeconomic status and the age of a population (Neidell, 2004). Our results are consistent with these findings. Parents who had national and/or international travel experience and resided in urban areas showed more concern about their children's health. Motor vehicle exhaust and dust caused by construction exacerbated parental concern about their children's health.
Our study has shown that parents perceive poor air quality to be linked with cough, dry throat pain (60.1%), and sneezing (49.5%) among exposed children. The majority of parents believed that motor vehicle emissions, secondhand smoke, and dust are the major influencing factors for adverse effects on their children's respiratory health. Our qualitative finding is in agreement with a report that used logistic regression to examine the effect of secondhand smoke exposure on public workers in Shanghai and suggested secondhand smoke was responsible for several respiratory health problems, including lung cancer and tracheitis (Li et al., 2009).
Aurrekoetxea and coauthors' (2016) study on secondhand smoke exposure on 4-yearold children in Spain showed 21.6% of the children were exposed to secondhand smoke at home and 47.1% elsewhere. The odds of quantifiable urinary cotinine in children dropped after the smoking ban took effect in public places. Quantifiable urinary cotinine was more likely in children whose parents smoked at home in their presence (Aurrekoetxea et al., 2016). It is important to prevent children from indoor exposure to lung irritants in order to promote their respiratory health. In particular, parents should be reminded that their activities, including smoking or using coal for cooking, can affect their children's health.
Based on the children's health risk factors associated with poor air quality, the government should take all possible measurements to improve air quality in Nanchang. Parents believe that the top three approaches for the government to improve air quality in Nanchang are to control and reduce pollution from industrial facilities, to increase public transportation and reduce use of private cars, and to control and reduce waste incineration. These findings were consistent with reports from other studies (Lee et al., 2014; Zhang et al., 2014), which is useful information to Nanchang government officials in their effort to control air pollution and improve air quality in Nanchang in the future.
This study was more complete than the 2013 survey study (Zhang et al., 2014) because it contained a larger sample size from both rural and urban areas, and included both healthy and sick children. Limitations, however, are present.
One limitation in this study is possible recall bias when parents answered questions on their children's respiratory status. Plus, the questionnaire didn't include parent's own contribution to air quality and the health of their children. The main limitation of this study is due to the focus on a narrowed target population: parents with children ages 2-10 years. Therefore, it is unclear if the perception about air quality and its effects on children's respiratory health is the same or different from parents who have children younger than 2 or older than 10 years.
Also, people living in cities usually believe their health is better than people living in the countryside, which might be a cognitive bias. Finally, the rating scale used in this survey is subjective to parental perception. More quantitative research should be conducted in order to obtain a more complete assessment about the effects of poor air quality on children's respiratory health in Nanchang, China.
Most parents who participated in this study reported believing that their children were in good health (69%). Parents' concern regarding their children's health, however, was quite different depending on their socioeconomic status and level of education. Promoting health education about how air quality affects children's health might be an effective measure to improve public knowledge and understanding of the effects of poor air quality, especially for low-socioeconomic status parents in the countryside who reported more worry about their children's health.
While it is true that air pollution is not a problem localized to any one city or country and it can be a serious health issue affecting many countries and regions of the world, the majority of parents who participated in this study believe that the government should place more control on industrial facilities, private cars, and waste incineration to improve the air quality and respiratory health conditions of children in Nanchang.
In addition to posing great risks to children's respiratory health, air pollution is an issue that ideally should be addressed by the government, as air pollution is a far-reaching problem that affects all people exposed. Therefore, when making any economic development plan or policy for a city, proper management for air quality should be an essential consideration. The public's perception could provide a constructive frame of reference for the government to consider when shaping policies.
The government is not the only entity with a duty to improve the air quality and respiratory health of children--the public also has to assume some responsibility. Based on the populace's knowledge and misgivings, the public should consider stopping unhealthy behaviors (such as to stop smoking both indoors and outdoors), stopping indoor cooking with coal and using more cleaner fuels, and limiting their use of private cars in favor of using public transportation (buses) or personal bicycle more often.
Zhaokang Yuan, MS, MD
School of Public Health, Nanchang University
Jay E. Maddock, MS, PhD
Yuanan Lu, MS, PhD
School of Public Health, Nanchang University
Office of Public Health Studies, University of Hawaii at Manoa
Acknowledgements: The authors want to express their great appreciation to the following collaborating agencies for their support of this study: East Lake District CDC and Jiangxi Provincial Children's Hospital, which provided support on the survey, especially East Lake District Kindergarten in Nanchang and Gaoxin District Primary School in Nanchang. This study was funded by Nanchang University through Dr. Yuanan Lu's Ganjiang Chair Professorship.
Corresponding Author: Yuanan Lu, Office of Public Health Studies, University of Hawaii at Manoa, Honolulu, HI 96822.
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TABLE 1 General Demographic Characteristics of Interviewees (N = 989) Characteristic # % Gender Male 373 37.7 Female 616 62.3 Educational level [less than or equal to] Junior high school 267 27.0 High school 207 20.9 [greater than or equal to] College 515 52.1 Place of residence City 660 66.7 Countryside 329 33.3 Average annual household income (yuan) <25,000 379 38.3 25,000-75,000 402 40.6 >75,000 208 21.0 Parents' age (years) * 20-30 305 30.8 31-40 604 61.1 >40 76 7.7 Travel experience Yes 919 92.9 Domestic travel 817 82.6 Overseas travel 102 10.3 No 70 7.1 Health status of child Healthy 496 50.2 Sick (selected in hospital) 493 49.8 * Mean age = 33.2; Standard deviation = 5.1. TABLE 2 Parents' Perceptions of Children's General Health Conditions Parent Characteristic Perceived General Health Condition Good Fair # % # % Gender Male 269 72.1 86 23.1 Female 415 67.4 160 26.0 Educational level [less than or equal to] 179 67.0 67 25.1 Junior high school High school 132 63.8 61 29.5 [greater than or 373 72.4 118 22.9 equal to] College Place of residence (a) City 474 71.8 157 23.8 Countryside 210 63.8 89 27.1 Average annual household income (yuan) <25,000 260 68.6 96 25.3 25,000-75,000 273 67.9 102 25.4 >75,000 151 72.6 48 23.1 Parents' age (years) (b) 20-30 180 59.0 91 29.8 31-40 448 74.2 134 22.2 >40 53 69.7 21 27.6 Travel experience Yes 659 71.7 215 23.4 Domestic travel 581 71.1 194 23.7 Overseas travel 78 76.5 21 20.6 No 25 35.7 31 44.3 Health status of child (c) Healthy 437 88.1 57 11.5 Sick (selected in hospital) 247 50.1 189 38.3 Perceived General Health Condition [chi p- Parent Characteristic Poor square] Value # % Gender 2.857 .240 Male 18 4.8 Female 41 6.7 Educational level 7.704 .103 [less than or equal to] 21 7.9 Junior high school High school 14 6.8 [greater than or 24 4.7 equal to] College Place of residence (a) 11.181 .004 City 29 4.4 Countryside 30 9.1 Average annual household 2.128 .712 income (yuan) <25,000 23 6.1 25,000-75,000 27 6.7 >75,000 9 4.3 Parents' age (years) (b) 36.639 <.001 20-30 34 11.1 31-40 22 3.6 >40 2 2.6 Travel experience 48.469 <.001 Yes 45 4.9 Domestic travel 42 5.1 1.645 .439 Overseas travel 3 2.9 No 14 20.0 Health status of child (c) 174.87 <.001 Healthy 2 0.4 Sick (selected in hospital) 57 11.6 (a) Orderly rank and inspection: Z = -2.846, p = .004. (b) Spearman rank correlation coefficient = -0.141, p = .000; Linear trend value = 22.253, p = .000. (c) Orderly rank and inspection: Z = -13.191, p = .000. TABLE 3 Frequency of Respiratory Conditions in Children Never < 1/yr 1-2/yr Date Disease # (%) # (%) # (%) April 2014 Asthma 898 (90.8) 47 (4.8) 20 (2.0) (n = 989) Allergies * 716 (72.4) 152 (15.4) 65 (6.6) Bronchitis * 522 (52.8) 188 (19.0) 175 (17.7) URI * 268 (27.1) 163 (16.5) 321 (32.5) Coughing * 94 (9.5) 177 (17.9) 370 (37.4) Wheezing * 876 (88.6) 53 (5.4) 28 (2.8) May 2013 Asthma 660 (91.5) 39 (5.4) 11 (1.5) (n = 721) Allergies 546 (75.7) 103 (14.3) 36 (5.0) Bronchitis 510 (70.7) 112 (15.5) 47 (6.5) URI 76 (10.5) 176 (24.4) 216 (30.0) Coughing 124 (17.2) 168 (23.0) 191 (26.5) Wheezing 661 (91.7) 37 (5.1) 7 (1.0) Chronic >3/yr Illness Date Disease # (%) # (%) April 2014 Asthma 21 (2.1) 3 (0.3) (n = 989) Allergies * 48 (4.9) 8 (0.8) Bronchitis * 98 (9.9) 6 (0.6) URI * 228 (23.1) 9 (0.9) Coughing * 335 (33.9) 13 (1.3) Wheezing * 29 (2.9) 3 (0.3) May 2013 Asthma 6 (0.8) 3 (0.7) (n = 721) Allergies 15 (2.1) 21 (2.9) Bronchitis 30 (4.2) 22 (3.1) URI 186 (25.8) 67 (9.3) Coughing 171 (23.7) 69 (9.6) Wheezing 10 (1.4) 6 (0.8) URI = upper respiratory infection. * Compared with 2013, p <.001. TABLE 4 Correlations Between Parents' Perception of Their Child's Health and Respiratory Conditions in Children * General Health Disease Conditions p-Value Asthma 0.037 .244 Allergies 0.095 .003 Bronchitis 0.173 <.001 URI 0.218 <.001 Coughing 0.204 <.001 Wheezing 0.047 .141 URI = upper respiratory infection. * The Spearman rank correlation coefficients between perceptions of general health conditions and
respiratory diseases in children. TABLE 5 Parent Concerns About Child's Respiratory Health When Air Quality Worsened Somewhat Parent Characteristic Very Worried Worried # % # % Gender Male 164 44.0 178 47.7 Female 318 51.6 260 42.2 Educational level [less than or equal to] 100 37.5 133 49.8 Junior high school High school 94 45.4 97 46.9 [greater than or equal 288 55.9 208 40.4 to] College Place of residence City 349 52.9 156 47.4 Countryside 133 40.4 282 42.7 Average annual household income (yuan) <25,000 161 42.5 185 48.8 25,000-75,000 201 50.0 171 42.5 >75,000 120 57.7 82 39.4 Parents' age (years) (b) 20-30 148 48.5 136 44.6 31-40 297 49.2 269 44.5 >40 35 46.1 31 40.8 Travel experience Yes 453 49.3 407 44.3 Domestic travel 390 47.7 369 45.2 Overseas travel 63 61.8 38 37.3 No 29 41.4 31 44.3 Not Parent Characteristic Considered Not Worried # % # % Gender Male 21 5.6 10 2.7 Female 23 3.7 15 2.4 Educational level [less than or equal to] 20 7.5 14 5.2 Junior high school High school 11 5.3 5 2.4 [greater than or equal 13 2.5 6 1.2 to] College Place of residence City 28 8.5 12 3.6 Countryside 16 2.4 13 2.0 Average annual household income (yuan) <25,000 19 5.0 14 3.7 25,000-75,000 20 5.0 10 2.5 >75,000 5 2.4 1 0.5 Parents' age (years) (b) 20-30 14 4.6 7 2.3 31-40 23 3.8 15 2.5 >40 7 9.2 3 3.9 Travel experience Yes 39 4.2 20 2.2 Domestic travel 38 4.7 20 2.4 Overseas travel 1 1.0 0 0.0 No 5 7.1 5 7.1 [chi Parent Characteristic square] p-Value Gender 6.322 .097 Male Female Educational level 38.591 <.001 [less than or equal to] Junior high school High school [greater than or equal to] College Place of residence 28.803 <.001 City Countryside Average annual household 17.707 .007 income (yuan) <25,000 25,000-75,000 >75,000 Parents' age (years) (b) 5.966 .743 20-30 31-40 >40 Travel experience 8.402 .038 Yes Domestic travel 10.278 .016 Overseas travel No (a) Nonparametric rank and inspection: [chi square] = 32.797, p = .000; Spearman rank correlation coefficient = 0.182, p = .000; Linear trend value = 37.456, p = .000. (b) Nonparametric rank and inspection: Z = -4.449, p = .000. (c) Nonparametric rank and inspection: [chi square] = 15.182, p = .000; Spearman rank correlation coefficient = 0.123, p = .000; Linear trend value = 16.338, p = .000. TABLE 6 Analysis of Risk Factors (Parents' Perception) Related to Children's Respiratory Conditions Upper Respiratory Bronchitis (a) Infection (b) Factors * Yes No Yes No Dust Did not affect 23 47 38 32 Affected a little 130 176 216 90 Affected strongly 314 299 467 146 Automobile Did not affect 12 29 21 20 emission Affected a little 102 135 162 75 Affected strongly 353 358 538 173 Second- Did not affect 23 22 34 11 hand Affected a little 94 140 164 70 smoke Affected strongly 350 360 523 187 Coughing (c) Factors * Yes No Dust Did not affect 57 13 Affected a little 276 30 Affected strongly 562 51 Automobile Did not affect 33 8 emission Affected a little 212 25 Affected strongly 650 61 Second- Did not affect 37 8 hand Affected a little 214 20 smoke Affected strongly 644 66 * The effect rank of factors that parents believed worsen child respiratory symptoms. (a) Dust (bronchitis): [chi square] = 12.491, p = .002; rs = 0.109, p = .031. Automobile emission (bronchitis): [chi square] = 8.647, p = .013; [r.sub.s] = 0.083, p = .009. Secondhand smoke (bronchitis): [chi square] = 6.166, p = .046; [r.sub.s] = 0.061, p = .032. (b) Dust (upper respiratory infection): [chi square] = 16.449, p = .000; [r.sub.s] = 0.109, p = .001. Automobile emission (upper respiratory infection): [chi square] = 14.992, p = .001; [r.sub.s] = 0.107, p = .001. (c) Dust (coughing): [chi square] = 7.723, p = .021; [r.sub.s] = 0.064, p = .044. FIGURE 1 Exhibited Symptoms as a Result of Worsened Air Quality Yes No Did Not Affect 49 940 Other 16 973 Irritability 125 864 Skin Allergies 210 779 Sneezing 490 499 Dry or Sore Throat 594 395 Stinging, Burning, or Itchy Eyes 230 759 Difficulty Breathing 100 889 Cough 373 616 Note: Table made from bar graph. FIGURE 2 Factors That Worsened Children's Symptoms Affected Not Affected Smog 902 87 Dust 919 70 Automobile Emission 948 41 Lack of Air Circulation due to Tall Building Wall 685 304 Construction 812 177 Chemical 828 161 Secondhand Smoke 944 45 Note: Table made from bar graph.[GRAPHIC OMITTED]
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