Asthma is the most common chronic diseases in the world. Economic and racial/minority disparities in the prevalence and extreme of asthma are researched well, with people belonging to low socio-economic status and racial/minority are more prone to have this chronic disease. It has been noticed that even after trying to control this disease, minorities and people from low socio-economic status are more likely to be hospitalized and yet still not treated fully. There is constant recurring of the same patients coming in for treatment of asthma. This tendency is particularly observed in the urban areas, where racial and ethnic minority who are normally economically disadvantaged people are exposed to asthma-related factors such as poor housing conditions, environmental tobacco smoke, crowding, air pollution, and other allergens. Additional research into these pathways is critical for the design of interventions to reduce the income and racial/ethnic discrepancies in the prevalence and effect of asthma as a leading cause of childhood morbidity. This paper discusses the prevalence, morbidity, mortality, factors contributing to a higher prevalence of asthma in racial and ethnic minorities. In the end the disparities in the asthma treatment in minorities is discussed.
Asthma Control and Treatment in Racial and Ethnic Minorities
Although asthma cannot be cured, effective treatments have been available for many years. Practice nurses can help to ensure these treatments are used effectively
Asthma is defined as a chronic inflammatory disease of the airways that presents as diffuse airways obstruction and is reversible either spontaneously or with treatment.
Prevalence, Morbidity, Mortality of Asthma In Racial And Ethnic Minorities
Asthma is the most common chronic disease especially in children, and thus prevailing in approximately 4.8 million children in the United States. Asthma is one of the major reasons for hospitalization. Different researches have found out that there is comparatively greater prevalence of asthma in people who belong to urban, racial and ethnic minorities, and low-socioeconomic backgrounds. Prevalence rates of asthma belonging to these backgrounds are found to be 10 percent to 20 percent while the prevalence for US children is 6 percent. These outcomes show that there is increased difference in the prevalence of asthma by racial/ethnic group: in Hispanics, Puerto Ricans have the highest asthma prevalence rate (19.6%), which is three times the prevalence for Mexicans (6.1%). Other racial/ethnic minorities include non-Hispanic Blacks whose prevalence of asthma is (13.8%) and non-Hispanic Whites (11.1%). (Homa, Mannino, Lara, 2000) In the US in 2000, asthma’s morbidity was 474,000 asthma hospitalizations and 11.9 million medical visits for the disease. Among the diverse U.S. Hispanic population, Puerto Ricans have the greatest annual asthma mortality (40.9 per million) followed by Cuban Americans (15.8 per million) and Mexican Americans (9.2 per million). In comparison, non-Hispanic whites had an annual asthma mortality of 14.7 per million, and non-Hispanic blacks had a rate of 38.1 per million. (Carr, Zeitel, Weiss, 2002)
In the US today, patterns of childhood asthma prevalence vary greatly according to socioeconomic status and racial/ethnic background. The highest prevalence and morbidity have occurred among Black children, particularly children of low socioeconomic status residing in large urban areas. It is argued that these racial/ethnic and economic asthma patterns are largely accounted for by social and environmental characteristics). Not often addressed are differences in asthma prevalence within low-income, urban, minority racial/ethnic groups. (Gent, Holford, Leaderer 1996) In particular, epidemiological studies of childhood asthma prevalence have found significant differences among Hispanic subgroups, with Puerto Ricans having the highest rates and Mexican Americans the lowest rates.
In the United States, asthma prevalence, hospitalization, and mortality are higher for Black/African American (racial/ethnic minority) compared to White Caucasian (majority) children and adults. In a Southfield, Michigan, cross-sectional study of childhood asthma in an integrated middle class population, the lifetime prevalence of asthma was twice as high for racial/ethnic minority compared with children from majorities; this finding suggests that even in middle class communities unmeasured socioeconomic factors (e.g., racial discrimination, differential access to medical care, differential access to housing, differential patterns of medical care use), and perhaps biologic factors, may contribute to these disparities. (Chen, Fisher, Bacharier, Strunk, 2003) The disparity in asthma morbidity is greater than the disparity in asthma prevalence, which suggests that once asthma is established, many factors converge to make asthma worse for children and adults who are from racial/ethnic minority.
Factors Contributing To A Higher Prevalence Of Asthma In Minorities
After taking into account exposures including cigarette smoke, body-mass index, air-conditioning use, city of residence, parental respiratory illness, parental education, only-child status, and single-parent household. Younger maternal age, residence in the central city, family income, low birth weight, and measures of overweight or obesity partially, but not fully, explain the increased prevalence of asthma among racial/ethnic minority compared with majority children. (Chen, Fisher, Bacharier, Strunk, 2003) Children from the racial/ethnic minority do not seem to have higher rates of asthma, but living in an urban setting, regardless of race or income, increased the risk of asthma.
Housing Conditions and Indoor Environmental Exposures Including Allergens
The degree of housing disrepair has been associated with increased cockroach allergen levels, which has been demonstrated to increase childhood asthma morbidity in sensitized children. (Homa, Mannino, Lara, 2000) Certain allergens, such as cockroach, mouse, or rat, may be more potent sources of allergic or non-allergic airway inflammation, or environmental cofactors such as community stress may increase vulnerability to the effects of these exposures in sensitized individuals and since mostly people having such living conditions are likely to belong to urban areas and also minorities (as explained earlier).
Maternal Cigarette Smoking
The respiratory health effects of smoking have been well documented. Maternal cigarette smoking is associated with high risk of asthma prevalence in early childhood, and with high risk of asthma morbidity, wheeze, and respiratory infection in children. Cigarette smoking varies by ethnicity and by national origin, and cigarette companies have targeted minorities in an attempt to increase smoking where rates have traditionally been low.
Disparities in Asthma and Somatic Growth (Low Birth Weight, Pre-maturity, and Obesity)
Smoking and other environmental factors influencing both fetal growth and asthma are more prevalent in many (but not all) socio-economically disadvantaged populations in the United States. Pre-maturity and low birth weight adjusted for gestational age can be influenced not only by maternal smoking, but also by placental insufficiency, maternal fetal nutrition, infection, and maternal psychological as well as physical stress. (Waser, 2002)The risk of all these environmental influences on adverse fetal growth may be higher in many socio-economically disadvantaged U.S. groups, increasing the risk of pre-maturity and low birth weight. Underweight and obesity may both be risk factors for wheeze or asthma, and paradoxically, they may even have similar origins in fetal life or early childhood. (Holgate, Price, 2005) The circumstances of urban living and socioeconomic disadvantage, as well as cultural factors, may contribute to obesity.
There is a renewed interest in the influence of psychological stress on asthma. Various socio-demographic characteristics (e.g., lower social class, ethnic minority status, gender) may predispose individuals to particular pervasive forms of chronic life stress, which may, in turn, be significantly influenced by the characteristics of the communities in which they live. (Busse, Kiecolt-Glaser, 1994) Minority group status may predispose individuals to pervasive chronic stressors (e.g., discrimination, racism) and societal factors that link minorities.
Disparities In Asthma Control And Treatment
Asthma is one of many chronic diseases in the United States in which disparities in treatment and access to care have been documented. Even those with apparently equal access to the same health care system may experience disparities in care, and communication with the medical system is far more subtle than expressions of overt racism. (Freidhoff, Togias 1996). Substantial disparities in children’s health and use of health services persist across racial, ethnic, and economic groups in the United States. Disparities in care for Hispanics and African Americans with asthma are well documented. Unfortunately, many patients with asthma suffer because of inadequate care provided by healthcare professionals. (Schaafsma, Raynorr 2003) Poor adherence by the patient to prescribed management, lack of access to care, or a combination of these problems are some the other key factors that result in increased morbidity and mortality.
Difficulty in English language proficiency has been reported to have a significant impact on multiple aspects of the health care experience of Hispanic children, including access to care, use of services, and health outcomes, with some studies finding that English language proficiency explains much of the impact of Hispanic origin on barriers to care and on differences in pediatric care. (Sullivan, 2003) For parents with limited English skills, the availability of medical providers and office staff with whom they can clearly and comfortably communicate may be indispensable for ensuring adequate access to health care for their children. Race/ethnicity, language, and family economic status are closely associated with each other and with other factors that may influence health care experiences. Owing to this interrelatedness, it is important for understanding health care disparities and policy recommendations to evaluate these factors simultaneously to see their independent effects. Other related factors may include insurance coverage, child health needs, and geographic location. Access to health care is limited for children with no medical insurance coverage. (Weiss, Sullivan, 2001)
Black and Hispanic children are more likely to lack health insurance, with Hispanics consistently found to be the most uninsured ethnic or racial group of children. Health insurance can have an important buffering effect on access to care among disadvantaged children, with public insurance helping to bring poor children closer to the levels of non-poor children with private insurance. However, disparities in care and the location of care can remain despite the provision of insurance. Children from different race/ethnic and economic backgrounds differ in the locations where they reside and in their health status, each of which can impact available options for care and interactions with medical providers. (Britton, 2003)
Secondhand cigarette smoke is documented to negate the benefit of inhaled corticosteroids in inner-city children. Unfortunately, many patients with asthma are smokers, including adolescents.
It is generally found that people belonging to low socio-economic status are usually from the minorities and thus do not have enough income to afford the expensive medicines for treatment. (Clark, Brown, Joseph, 2002) Physicians normally know their economic status and avoid prescribing expensive medicine which is actually required to treat the patient of asthma effectively. At this point in time, the physicians prescribe those medicines which are easily available and easy to buy even for the poor family. This results in in-effective treatment of poor asthma patients and thus they tend to get hospitalized again and again which no output.
Poor environmental control contributes to bad outcomes for inner-city children, while reduced exposure to aeroallergens improves outcomes. Significant racial disparities in asthma treatment have been found among patients in analyses of several state Medicaid programs.
While Hispanics and blacks had a significantly higher rate of visits to the emergency department for asthma as compared to whites, the number of filled prescriptions for inhaled corticosteroids and visits to asthma specialists were more common in whites as compared to Hispanics and Blacks. (Britton, 2003) Although the mental health of the parents is not usually considered in analyses of pediatric asthma control, one study found that an independent risk factor for emergency department visits among minority children with asthma was the presence of depression in the mother.
Income, which is associated with race/ethnicity, explains some but not all of the disparity. Economic disadvantage is an important factor in the racial/ethnic readmission gap; however, the analysis shows that the observable economic factors do not fully explain the gap. The simple ability to afford health care does not fully explain outcomes. Health insurance plays an important role in the proper management of asthma. Medicaid patients have readmission rates that are 50% higher than privately insured patients, which show that improvements must be made in the discharge and follow-up of Medicaid patients. (Britton, 2003) Yet again, the racial/ethnic gap in readmission is not explained by Medicaid coverage. There are racial/ethnic differences in the prescription and the use of preventive medications within the Medicaid population.
The effects of individual environmental factors on asthma morbidity and asthma development are likely to be modified by other environmental factors and by genes. (Freidhoff, Togias, 1996) With the exception of cigarette smoking cessation, policy makers should be cautious when recommending global solutions for protection against development of early-life asthma, given the lack of certainty regarding factors influencing asthma development and the likelihood that individual responses to environmental interventions will be significantly modified by genetic and other environmental factors.
It is not trite to say that “more research is needed” to improve our understanding of factors responsible for disparities in asthma prevalence. However, where community-level or individual-level interventions have been demonstrated to decrease asthma morbidity with reasonable certainty, policy makers should develop the means to apply the lessons learned through changes in governmental and social policy as well as through recommendations to individuals. Subsequently, the outcome of changes in policy should be systematically evaluated. In the United States, effective reduction in disparities in asthma morbidity will be dependent only in part on specific measures like establishment of smoking cessation programs, home allergen reduction in sensitized asthmatic children, physician feedback, and/or health education. The long-term success of any of these specific measures is likely to depend, in great part, on more general improvements in living conditions and life opportunities.
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