NHLBI Workshop Summary
Reducing disparities in asthma care: Priorities for research—National Heart, Lung, and Blood Institute Workshop Report,☆☆,

https://doi.org/10.1067/mai.2002.120950Get rights and content

Abstract

Minority groups with diverse racial and ethnic heritages and persons living in poverty are much more likely to die of asthma and to require emergency care for exacerbations of asthma than white persons not living in poverty. The National Heart, Lung, and Blood Institute convened a multidisciplinary group of expert scientists and clinicians to review current research aimed at understanding risk factors for these disparities in asthma health outcomes, to describe key barriers to improving asthma outcomes, and to establish priorities for future research. Education programs for asthma and other chronic diseases were reviewed. Successful elements of clinic and community-based programs were identified. Factors potentially involved in producing disparities include gene-environment interaction, psychologic and social factors, and socioeconomic status. Stress potentially contributes to asthma morbidity at both the individual and community level. Recommendations are made to stimulate research to understand risk factors for disparities and their mechanisms (eg, gene-by-environment interactions and the role of stress), to define appropriate research designs and methods for evaluating behavioral and community interventions, and to examine how differential access to care contributes to morbidity. Research is encouraged to identify strategies that improve cultural adaptation and adoption of proven programs in a variety of populations. (J Allergy Clin Immunol 2002;109:229-37.)

Section snippets

Education of patients about asthma management

A number of randomized trials have demonstrated that education about asthma and encouragement for self-management substantially reduces the risk of emergency department visits, hospitalizations, and lost days of work when compared with usual care.22 Characteristics of effective programs are (1) teaching patients to self-monitor, (2) giving patients a written treatment plan that allows self-adjustment of medications, and (3) offering or providing regular appointments to review the progress of

Gene-environment interaction

Asthma is a heritable trait, but genetic factors alone cannot explain the rise in asthma prevalence, morbidity, or mortality.43 However, a small change in the prevalence of relevant environmental exposures could explain a significant rise in disease prevalence among genetically susceptible individuals.44 Gene-environment interaction, defined as the coparticipation of genetic and environmental factors,45, 46 is particularly relevant to the cause of asthma morbidity in racial-ethnic minorities

Rethinking the framework of asthma care

Various strategies can improve asthma management, including asthma-education interventions focused on building patient self-efficacy and self-management skills, diagnostic and treatment support, and use of specialty services. In addition, system performance measurement and more complex strategies, such as case-management interventions and disease-management programs, have been and continue to be tested. These differing types of health care delivery strategies have begun to form the foundation

Evaluation designs for community-based behavior-change interventions

Because disparity in the outcome of asthma care is a public health problem, approaches to reduce disparities are often studied at a community level. Such approaches are complex and ever changing, operating on multiple levels with multiple strategies and often changing as community members work together. Research on community-based behavior-change interventions should not only identify ways to improve asthma care but should also increase understanding of the processes associated with program

Definition of risk factors underlying disparity

Although asthma is a heritable trait, it is unlikely that genetic factors alone explain either the rise in asthma prevalence or the disparities in outcome. However, gene-by-environment interactions likely play a role in determining disease severity and possibly prevalence. Two fundamental environmental areas, psychologic and social factors, as well as physical environment, were discussed, and their interactions were considered. Psychosocial factors, such as stress, depression, cultural beliefs,

References (87)

  • D Coultas et al.

    Respiratory diseases in minorities of the United States

    Am J Respir Crit Care Med

    (1993)
  • W Taylor et al.

    Impact of childhood asthma on health

    Pediatrics

    (1992)
  • R Evans et al.

    National trends in the morbidity and mortality of asthma in the US: prevalence, hospitalization and death from asthma over two decades: 1965-1984

    Chest

    (1987)
  • Centers for Disease Control

    Asthma United States 1980

    MMWR Morb Mortal Wkly Rep

    (1990)
  • K Weiss et al.

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

    JAMA

    (1990)
  • D Lang et al.

    Patterns of asthma mortality in Philadelphia from 1969-1991

    N Engl J Med

    (1994)
  • D Mannino et al.

    Surveillance for Asthma–United States, 1960-1995.CDC Surveillance Summaries, April 24, 1998

    MMWR Morb Mortal Wkly Rep

    (1998)
  • K Weiss et al.

    Geographic variations in U.S. asthma mortality: small-area analyses of excess mortality, 1981-1985

    Am J Epidemiol

    (1990)
  • F Malveaux et al.

    Environmental risk factors of childhood asthma in urban centers

    Environ Health Perspect

    (1995)
  • W Carr et al.

    Variations in asthma hospitalization and deaths in New York City

    Am J Public Health

    (1992)
  • K Weiss et al.

    Examining issues in health care delivery for asthma: background and workshop overview

    Med Care

    (1993)
  • R. Evans

    Asthma among minority children: a growing problem

    Chest

    (1992)
  • M Weitzman et al.

    Recent trends in the prevalence and severity of childhood asthma

    JAMA

    (1992)
  • P Gergen et al.

    Changing patterns of asthma hospitalization among children: 1979 to 1987

    JAMA

    (1990)
  • E Crain et al.

    Wheezy illness without asthma: the burden of illness in an inner-city pediatric population

    Am J Dis Child

    (1993)
  • N Halfon et al.

    Childhood asthma and poverty: differential impacts on utilization of health services

    Pediatrics

    (1993)
  • P Eggleston et al.

    Medications used by children with asthma living in the inner city

    Pediatrics

    (1998)
  • J Finkelstein et al.

    Quality of care for preschool children with asthma: the role of social factors and practice setting

    Pediatrics

    (1996)
  • P Gibson et al.

    Self-management education and regular practitioner review for adults with asthma (Cochrane Review)

    (1999)
  • M Partridge et al.

    Enhancing care for people with asthma: the role of communication, education, training, and self-management

    Eur Respir J

    (2000)
  • M Ford et al.

    Health outcomes among African American and Caucasian adults following a randomized trial of an asthma education program

    Ethn Health

    (1997)
  • J Donahue et al.

    Inhaled steroids and the risk of hospitalization for asthma

    JAMA

    (1997)
  • N Clark et al.

    Impact of education for physicians on patient outcomes

    Pediatrics

    (1998)
  • N Clark et al.

    Long-term effects of asthma education for physicians on patient satisfaction and use of health services

    Eur Respir J

    (2000)
  • N Clark et al.

    Long-term effects of asthma education for physicians on patient satisfaction and use of health services

    Eur Respir J

    (2000)
  • S Fortmann et al.

    Changes in adult cigarette smoking prevalence after 5 years of community health education: the Stanford Five-City Project

    Am J Epidemiol

    (1993)
  • H Lando et al.

    Changes in adult cigarette smoking in the Minnesota Heart Health Program

    Am J Public Health

    (1996)
  • R Leupker et al.

    Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health program

    Am J Public Health

    (1994)
  • E Fisher

    The results of the COMMIT trial. Editorial

    Am J Public Health

    (1995)
  • R Secker-Walker et al.

    Helping women quit smoking: results of a community intervention program

    Am J Public Health

    (2000)
  • E Fisher et al.

    Neighbors For a Smoke Free North Side: evaluation of a community organization approach to promoting smoking cessation among African Americans

    Am J Public Health

    (1998)
  • R Beasley et al.

    Trial of an asthma action plan in the Maori community of the Wairarapa

    N Z Med J

    (1993)
  • L. Pachter

    Culture and clinical care: folk illness beliefs and behaviors and their implications for health care delivery

    JAMA

    (1994)
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    Supported by the National Heart, Lung, and Blood Institute, Division of Lung Diseases.

    ☆☆

    *Workshop participants are listed in the appendix.

    Reprint requests: Robert C. Strunk, MD, Department of Pediatrics, Washington University School of Medicine, Division of Allergy and Pulmonary Medicine, St Louis Children's Hospital, 1 Children's Place, St Louis, MO 63108.

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