The Potential for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors

doi:10.1378/chest.07-1908

Chest

Volume 132, Issue 5, Supplement, November 2007, Pages 789S-801S

https://doi.org/10.1378/chest.07-1908 Get rights and content

The National Workshop To Reduce Asthma Disparities assembled a multidisciplinary group comprised of scientists, clinicians, and community representatives to examine factors related to asthma disparities. Attention was given to the importance of discerning family, social, and behavioral factors that facilitate or impede the use of health-care services suitable to the medical status of an individual. This review highlights select biopsychosocial factors that contribute to these disparities, the manner in which they may contribute or protect persons affected by asthma, and recommended directions for future research.

Section snippets

Social, Economic, and Environmental Interactions

Disparities are most apparent among populations with varying levels of socioeconomic status (SES). Significant evidence has demonstrated that a gradient exists between SES and health status, with individuals of high SES having better overall health that those of low SES.23, 24, 25, 26, 27 Many hypothesize that the health disparities seen across SES levels are due to health-care access. Yet in industrialized nations with universal health-care systems, an SES gradient exists in all causes of

Social Networks and Social Support

Social networks and social support are interpersonal processes that influence health. Social support is the commitment, caring, advice, and aid provided through relationships or networks of people. These networks can have direct effects on health through emotional and instrumental support.³⁷ They also provide social ties with meanings and obligations that influence health behaviors, thereby influencing morbidity and mortality.³⁷

Research has indicated that social relationships have a significant

Family

Although the relationship between family functioning and asthma management and morbidity has received little attention in the literature, family support and functioning play a role in health outcomes. There is evidence that the family may serve as a protective factor for health,37, 65, 66 and act as a buffer from negative life events in patients with asthma.⁶⁷ Research has indicated that functional families may facilitate adherence and reduce morbidity in children with chronic illnesses,68, 69

Stress

The physiologic impact of stress on psychological functioning, behavior, and the endocrine, immune, and central nervous systems has led researchers to identify stress as a precipitating factor for cardiovascular diseases, endocrine dysfunctions, autoimmune disorders, and cancer. Similarly, high levels of stress have been empirically found to predispose people to asthma, precipitate its development, and predict both asthma morbidity and poorer quality of life.101, 102, 103, 104, 105, 106, 107

Coping

While stress is the physiologic response to perceived (both real and imagined) threats to a person's mental, physical, emotional, and spiritual well being, coping is the manner in which a person responds and adapts behaviorally, cognitively, and emotionally to environmental or internal circumstances.93, 120 Therefore, when an individual judges their coping to be inadequate, the result is psychological stress.¹²¹ Adequate coping can facilitate the acceptance of an asthma diagnosis, adherence to

Knowledge, Attitudes, Beliefs, and Health Practices

Self-management education for both caregivers and patients facilitates problem-focused coping. An expanding body of research indicates that patients who possess a better understanding of their diagnosis, treatment, and care are able to adopt skills to better manage their disease, experience less asthma morbidity, and reduce their utilization of health-care services and lost days of work.130, 131, 132 Additionally, patient education has the capacity to modify patients' attitudes, beliefs, and

Future Directions

Many family, social, and behavioral factors contribute to asthma disparities both directly and indirectly. The relationships between these factors and the mechanisms by which they contribute to disparities are complex. Family, social, and behavioral factors indirectly affect disparities by affecting the resources (physical, economic, psychological, and social) to which persons have access and the health behaviors they perceive to be important vs those which they neglect. The challenge for

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La desigualdad socioeconómica (DSE) puede afectar negativamente al control del asma. El objetivo de este estudio fue identificar la relación de la DSE con el control del asma y la calidad de vida de los cuidadores.
El nivel socioeconómico se determinó por área de residencia, según la tasa de riesgo de pobreza (TRP). La población pediátrica de Castilla y León se estratificó en terciles de TRP, y se seleccionó una muestra mediante muestreo aleatorio estratificado, identificando a los niños (6-14 años) con asma activa en los registros clínicos de centros de atención primaria. La información se obtuvo mediante cuestionarios cumplimentados por los padres. Las variables primarias fueron el control del asma y la calidad de vida de los cuidadores. Se analizó su relación con la DSE, la calidad de la atención sanitaria y factores individuales (como el nivel educativo de los padres) mediante modelos multivariantes de regresión.
El tercil de TRP no se relacionó con ninguna medida de control del asma, calidad de vida ni calidad de la asistencia. El nivel educativo de la madre (educación media o superior) se asociaba a menor riesgo de consulta no programada/urgente (OR = 0,50; IC 95%: 0,27-0,95; p = 0,034) y el del padre a menor riesgo de asma mal controlada (OR = 0,51; IC 95%: 0,28-0,94; p = 0,030).
En la población que hemos estudiado, no se encuentra asociación entre DSE, medida por área de residencia, y el control del asma en niños. Otros factores, como la educación de los padres, pueden ser factores protectores.
Socioeconomic inequality (SEI) can adversely affect asthma control. The aim of this study was to establish the association of SEI with asthma control in children and caregiver quality of life.
We assessed socioeconomic status based on the area of residence, according to the at risk of poverty rate (ARPR). After stratifying the paediatric population of Castilla y León (an autonomous community in Spain) in ARPR tertiles, we selected participants by stratified random sampling, and identified children with asthma aged 6–14 years from the health records of primary care centres. We collected data through questionnaires completed by parents. The primary outcomes were asthma control and caregiver quality of life. We assessed their association with SEI, health care quality measures and individual factors (such as parental educational attainment) by means of multivariate regression models.
The ARPR tertile was not associated with asthma control, quality of life or health care quality. A medium or high maternal educational attainment was associated with a lower risk of making an unscheduled or urgent visit (OR=.50; 95% CI: .27-.95; P=.034) and paternal educational attainment was associated with a lower risk of uncontrolled asthma (OR=.51; 95% CI: .28-.94; P=.030).
In the sample under study, SEI assessed at the local level was not associated with asthma control in children. Other factors, such as parental educational attainment, may have a protective effect.
Impacts of online peer support for children with asthma and allergies: "It just helps you every time you can't breathe well"
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Citation Excerpt :
Positive exchanges with social networks can improve people's sense of self- esteem; reduce isolation; and, influence self-care (Buston & Wood, 2000; Kyngas, 2004; Stewart, 2000; Uchino, 2004). Some authors have suggested that traditional asthma and allergy education programs emphasize medication management and allergen avoidance, whereas children are focused on “being normal” (Mandell et al., 2005; Mangan, Wittich, & Gerald, 2007; Protudjer, Kozyrskyj, & Becker, 2011; Protudjer et al., 2009). Peer relationships are important to children, and peer support is particularly significant for children with chronic illness (Cohen, Frnaco, Motlow, Resnick, & Ozuah, 2003; Kyngas, 2004; Murray et al., 2006; Protudjer et al., 2009, 2011; Yang et al., 2009).
Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Support was delivered by peer mentors with asthma and allergies and a professional. Weekly support groups were conducted over 8 weeks using Go to Meeting and Club Penguin. Quantitative measures and a qualitative interview were administered. Significant increases in perceived support and support-seeking coping and trends in decreased loneliness emerged at post-test. Participants also reported increased self-confidence and satisfaction with the intervention.
Challenges in Providing Preventive Care To Inner-City Children with Asthma
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Several psychosocial factors are also known to create barriers to preventive care for children with asthma. In particular, caregiver psychological symptoms and life stress related to residence in low-income, inner-city communities negatively influence decisions about asthma self-management and increase asthma morbidity through treatment nonadherence and unnecessary use of health care.52–56 Both caregiver anxiety and depressive symptoms are associated with poor asthma outcomes,57,58 but research with inner-city populations increasingly suggests that caregiver depression is a particularly strong predictor of child asthma attacks,59 ED visits,60 and hospitalizations.61
Relationship between recent short-acting β-agonist use and subsequent asthma exacerbations
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Despite better understanding of asthma pathophysiology and new treatment modalities, cases have more than doubled since 1980 and death rates have increased during that time as well.2 Furthermore, during the last 20 years, asthma hospitalizations have doubled in adults and increased 5-fold in children.3 Therefore, identifying individuals at risk for asthma exacerbations is of utmost importance in the clinical management of this disease.
US national guidelines recommend assessing short-acting β-agonist (SABA) medication use as a marker of asthma severity and control. However, the relationship between recent SABA use and asthma exacerbations is not currently known.
To evaluate the proximal relationship between the type and frequency of SABA use and asthma-related outcomes.
We evaluated SABA use among patients with asthma ages 5 to 56 years who were members of a large health maintenance organization in southeast Michigan. Frequency of use was estimated from pharmacy data assessing the timing and amount of SABA fills. Cox proportional hazards models were used to examine the prospective relationship between average daily SABA use for 3 months and outcomes associated with poor asthma control (ie, oral corticosteroids use, asthma-related emergency department visits, and asthma-related hospitalizations). We separately accounted for SABA metered-dose inhaler (MDI) and SABA nebulizer use.
Of the 2,056 patients who met study criteria, 1,569 (76.3%) had used a SABA medication in their baseline year. After adjusting for potential confounders, SABA nebulizer use was associated with asthma-related emergency department visits (adjusted hazard ratio [aHR], 6.32; 95% confidence interval [CI], 2.38 to 16.80) and asthma-related hospitalizations (aHR, 21.62; 95% CI, 3.17 to 147.57). In contrast, frequency of SABA MDI use was not associated with these outcomes.
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Chest

The Potential for Reducing Asthma Disparities Through Improved Family and Social Function and Modified Health Behaviors

Section snippets

Social, Economic, and Environmental Interactions

Social Networks and Social Support

Family

Stress

Coping

Knowledge, Attitudes, Beliefs, and Health Practices

Future Directions

Ann Allergy Asthma Immunol

Chest

Chest

J Allergy Clin Immunol

Respir Med

J Allergy Clin Immunol

Lancet

Soc Sci Med

Soc Sci Med

Soc Sci Med

Pain Manage Nurs

Psychoneuroendocrinology

Soc Sci Med

Soc Science Med

Soc Sci Med

Ambul Pediatr

J Allergy Clin Immunol

J Psychosom Res

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Summary health statistics for U.S. children: National Health Interview Survey, 2000

Vital Health Stat 10

Self reported asthma prevalence among adults, United States, 2000

MMWR Morb Mortal Wkly Rep

Variations in asthma hospitalizations and deaths in New York City

Am J Public Health

Surveillance for asthma–United States, 1980–1999

MMWR Morb Mortal Wkly Rep

Asthma in the United States: burden and current theories

Environ Health Perspect

Surveillance for asthma–United States 1960–1995

MMWR Morb Mortal Wkly Rep

Impact of childhood asthma on health

Pediatrics

Changing patterns of asthma mortality: identifying target populations at high risk

JAMA

Current trends: asthma–United States

MMWR Morb Mortal Wkly Rep

Asthma mortality in U.S: Hispanics of Mexican, Puerto Rican, and Cuban heritage, 1990–1995

Am J Respir Crit Care Med

Unequal treatment: confronting racial and ethnic disparities in healthcare

National Academy Press. Washington, DC

Clearing the air: asthma and indoor air exposures

National Academy Press

The 21st century environment and air quality influences on asthma

Curr Opin Pulm Med

Regressive logistic modeling of familial aggregation for asthma in 7,394 population-based nuclear families

Genet Epidemiol

Psychometric performance of the Asthma Quality of Life Questionnaire in a US sample

Qual Life Res

Measuring quality of life in asthma

Am J Respir Crit Care Med

Employment grade and coronary heart disease in British civil servants

J Epidemiol Commun Health

Health inequalities among British civil servants: the Whitehall II study

Lancet

The society and population health reader: income inequality and health

New York Press

Social determinants of health

Oxford University Press

Race, socioeconomic status, and health: the added effects of racism and discrimination

Ann N Y Acad Sci

Socioeconomic status and chronic stress: does stress account for SES effects on health?

Ann N Y Acad Sci

Understanding sociodemographic differences in health: the role of fundamental social causes

Am J Public Health

Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults

JAMA

Racial differences in illness behavior

J Community Health