Neighborhood-level risk and resilience factors: an emerging issue in childhood asthma epidemiology

Evaluation of: Gupta RS, Zhang X, Sharp LK, Shannon JJ, Weiss KB. The protective effect of community factors on childhood asthma. J. Allergy Clin. Immunol. 123(6), 1297–1304.e2 (2009).

The recent increase in the prevalence of asthma in children is now recognized as the result of a complex interplay of genetic, sociodemographic and environmental factors. Multilevel models simultaneously account for neighborhood characteristics that may be related to childhood asthma, independently of individual-level attributes. Most research that focuses on the physical and social characteristics of neighborhoods to explain disparities in childhood asthma assess such factors as persistent poverty, residential racial segregation and environmental degradation. Researchers have only begun to test models that specifically focus on risk and protective factors at the community/neighborhood level in relation to asthma. Social capital, which measures norms of reciprocity, social ties between neighborhood residents and civic engagement has the potential to buffer the effects of neighborhood risk factors on childhood asthma. Further research, specifically longitudinal studies, needs to be carried out to determine whether findings on neighborhood-level risk and protective factors can guide the development of preventive interventions for childhood asthma.     

Asthma hospitalizations among US military personnel, 1994 to 2004.

BACKGROUND: Acute asthma attacks strike unpredictably and may lead to hospitalization in otherwise healthy individuals. The burden of asthma hospitalization on the US health care system has greatly interested health care workers, many of whom see the incidence of asthma as increasing. OBJECTIVES: To examine the annual incidence of hospitalization and the frequency of subsequent hospitalization for asthma among all active-duty US military personnel between 1994 and 2004 and to determine demographic and occupational risk factors of asthma hospitalization within this generally healthy US population. METHODS: Annual demographic and occupational data were combined with electronic hospitalization records for patients with a discharge diagnosis of asthma. Using Cox proportional hazard modeling, the authors investigated demographic and occupational risk factors for asthma hospitalization. RESULTS: Women, married persons, health care workers, enlisted personnel, US Army personnel, and older persons were found to have a significantly greater risk of asthma hospitalization. Yearly rates of hospitalization declined from 22.3 per 100,000 persons to 12.6 per 100,000 persons between 1994 and 2004. CONCLUSIONS: Although these data have some limitations, they suggest that the burden of asthma hospitalizations in the large, healthy population of US military personnel has declined during the last decade. The decrease in hospitalization potentially reflects improved outpatient management strategies.     

Advances in adult and pediatric asthma

This year we present updates on the management and therapeutics of asthma and research on the relationship of airway remodeling to clinically irreversible disease and continue a discussion about the origins of asthma. Significant advances are occurring in our understanding of the natural history of asthma, including the application of biomarkers and genetics. These tools should assist the clinician in defining patients at risk for significant morbidity related to asthma. Incorporating this knowledge will help prompt the development of more effective management techniques and new medications. Meanwhile, more effective health care strategies must be developed to reduce the reported disparities in asthma care noted in our patient populations.     

Multiple urban and asthma-related risks and their association with asthma morbidity in children

OBJECTIVE: To determine whether a multi-dimensional cumulative risk index (CRI) is a stronger predictor of asthma morbidity in urban, school-aged children with asthma, than poverty or severity alone. METHODS: A total of 163 children with asthma, ages 7-15 years (42% female; 69% ethnic minority) and their primary caregivers completed interview-based questionnaires, focusing on potential cultural, contextual, and asthma-specific risks that can impact asthma morbidity. RESULTS: Higher levels of cumulative risks were associated with more asthma morbidity, after controlling for poverty level or asthma severity. Analyses by ethnic group and subgroup also supported the relationship between the CRI and specific indices of asthma morbidity. CONCLUSIONS: This study demonstrates the utility of multiple-dimensional risk models for predicting variations in asthma morbidity in urban children. Research efforts with urban families who have children with asthma need to consider the context of urban poverty as it relates to children's cultural backgrounds and specific asthma outcomes.     

Young,African American adults with asthma: what matters to them?

BackgroundAsthma is a common chronic condition that shows significant health disparities among minority populations. Little research has focused on the management needs and preferences of young African American adults with asthma, a population undergoing dramatic life changes as they transition from adolescence to adulthood.ObjectiveTo understand the experiences and perspectives of young African American adults managing their asthma.MethodsFocus groups were conducted with African American adults (n = 34) 18 to 30 years old with a physician diagnosis of asthma. Focus group sessions were audiotaped, transcribed verbatim, and coded using constant comparative analysis.ResultsSix major domains were identified and some of the salient themes included changes in asthma management needs with the onset of adulthood, career limitations owing to asthma, childcare interference with asthma regimen adherence, and difficulties with medication cost owing to lapses in insurance coverage. Participants also reported feeling discouraged when interacting with physicians as it related to their asthma care; yet ageism and racism were not perceived. Despite poor medication regimen compliance, participants were overwhelmingly interested in participating in asthma self-management programs and had strong preferences that such programs be tailored specifically to young adults with special consideration of the cultural experience of young African Americans with asthma.ConclusionYoung African American adults have specific barriers to optimal asthma care and distinctive ideas for self-management programs. It is important for the asthma care provider to identify and address these population- and age-specific barriers to improve asthma outcomes and decrease health care disparities.     

Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma.

BACKGROUND: Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care. OBJECTIVE: To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma. METHODS: We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study. RESULTS: Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables. CONCLUSIONS: A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.     

Special presentation: self-management of asthma programs in the USA

In the USA during the past 5 years, there has been a renaissance of scientific interest and research into health education and programs of self-management. It has not, however, always been possible to translate gains in healthy individuals into similar progress for persons with chronic illness. Among chronic disorders affecting children, asthma ranks as a prominent cause of morbidity and school absenteeism. To accomplish this, NIH and NIAID has supported a variety of asthma self-management programs aimed at enhancing knowledge of disease among patients and parents. A further goal has been to translate this knowledge to changes in behavior in order to reduce morbidity of disease. The most successful programs have been conducted by non-physician health care professionals (nurses, social workers, teachers). The least successful programs have included mass distribution of printed materials by pharmaceutical companies and lay organizations. It is believed that broader application of such programs will help not only the patient but the physician improve the care of asthmatic individuals.     

Modifiable determinants of healthcare utilization within the African-American population

BACKGROUND: Significant health disparities directly affect the African-American population. Most previous studies of disparities in access to and utilization of healthcare have focused on black-white differences rather than focusing on "within-group" analysis of African Americans. OBJECTIVE: To tease out the differential effects of modifiable risk factors (such as health insurance, usual source of care, and poverty) from personal characteristics (age, gender, rural residence) on healthcare utilization within the African-American population. METHODS: Secondary data analysis of 3462 records from African-American respondents to the 1999 Medical Expenditure Panel Survey (MEPS) Household File, a nationally representative survey of the civilian, noninstitutionalized U.S. population in 1999. RESULTS: We found significant variation in the number of office visits, outpatient clinic visits, hospital discharges, days hospitalized, and fills of prescribed medication among 3462 African-American respondents who represent a U.S. population of 36,538,639 persons. Personal nonmodifiable characteristics such as age and gender were significantly related to healthcare utilization. Poverty and rural residence were also significantly correlated, but the strongest modifiable predictors of healthcare utilization for Afrcan-American persons in 1999 were whether or not individuals had health insurance and/or a usual source of care. Emergency department visits were the only form of care that showed remarkably little variation based on these modifiable risk factors. CONCLUSIONS: The three modifiable factors of poverty, uninsurance, and having a primary care medical home have a dramatic effect on patterns of care for African-American patients and could be independently targeted for intervention.     

Asthma morbidity and treatment in the Chicago metropolitan area: one decade after national guidelines.

BACKGROUND: A number of studies have demonstrated disproportionate hospitalization and mortality rates in US urban areas. Yet, no published population-based studies have examined the burden of asthma on the residents of a particular urban area known to be at high risk for poor asthma outcomes. OBJECTIVES: To examine asthma morbidity and medical care in a population-based sample of adults and children with asthma residing in the greater Chicago, IL, metropolitan area and to explore social and demographic influences on morbidity and treatment. METHODS: A telephone survey of adults living in the Chicago metropolitan area was conducted from November 1999 through December 2000. RESULTS: The final sample included 152 adults and children with active asthma. Emergency department visits and hospitalizations for asthma in the previous year were reported by 25.7% and 6.6% of respondents, respectively. Of current medication users, 32.2% reported current regular use of controller medications. After adjusting for age, sex, income, education, and reported current pharmacotherapy, compared with white individuals, African American individuals remained 6.3 times more likely to have experienced an emergency department visit and 12.3 times more likely to have been hospitalized. CONCLUSIONS: These findings suggest that poorly controlled asthma remains a prevalent problem for persons with asthma in this metropolitan area and that a large gap remains between the goals of asthma therapy and appropriate treatment as defined by the National Asthma Education and Prevention Program. The reasons for disparate treatment and health outcomes by race/ethnicity and income need further study and intervention.     

Beyond the horizon: the role of academic health centers in improving the health of rural communities.

Academic health centers (AHCs) face increasing pressures from federal, state, and community stakeholders to fulfill their social missions to the communities they serve. Yet, in the 21st century, rural communities in the United States face an array of health care problems, including a shortage of physicians, health problems that disproportionately affect rural populations, a need to improve quality of care, and health disparities related to disproportionate levels of poverty and shifting demographics. AHCs have a key role to play in addressing these issues. AHCs can increase physician supply by targeting their admissions policies and educational programs. Specific health concerns of rural populations can be further addressed through increased use of telemedicine consultations. By partnering with providers in rural areas and through the use of innovative technologies, AHCs can help rural providers increase the quality of care. Partnerships with rural communities provide opportunities for participatory research to address health disparities. In addition, collaboration between AHCs, regional planning agencies, and rural communities can lead to mutually beneficial outcomes. At a time when many AHCs are operating in an environment with dwindling resources, it is even more critical for AHCs to build creative partnerships to help meet the needs of their regional communities.     

Intimate Partner Violence and HIV: A Review

Intimate partner violence (IPV) is a common and negative social determinant of health. IPV also increases vulnerability to risks associated with HIV transmission and contributes to HIV transmission. IPV is therefore predictably common among people living with HIV. It is increasingly being recognized as an important predictor of poor outcomes for those living with HIV by affecting retention to care, mental health, adherence to therapy, frequency of follow-up; all of which lead to more hospitalizations and progression to AIDS. HIV care providers can safely and effectively screen all HIV patients for IPV. Screening offers the opportunity to identify those at risk for poor outcomes and mitigate its effects. Further research is required in further defining the risk factors and outcomes of IPV and optimizing interventions. We review the association between HIV infection and IPV and make recommendations for IPV screening of HIV-positive individuals and those at high risk for HIV.     

Race disparities in childhood asthma: does where you live matter?

OBJECTIVE: This study investigates whether racial/ethnic disparities in childhood asthma prevalence can be explained by differences in family and neighborhood socioeconomic position (SEP). METHODS: Data were from the 2001 Rhode Island Health Interview Survey (RI HIS), a statewide representative sample of 2,600 Rhode Island households, and the 2000 U.S. Census. A series of weighted multivariate models were fitted using generalized estimating equations (GEE) for the logistic case to analyze the independent and joint effects of race/ethnicity and SEP on doctor-diagnosed asthma among 1,769 white, black and Hispanic children <18 years old. RESULTS: Compared with white children, black children were at increased odds for asthma and this effect persisted when measures of family and neighborhood SEP were included in multivariate models (AOR: 2.49; 95% Cl: 1.30-4.77). Black children living in poverty neighborhoods had substantially higher odds of asthma than Hispanic and white children in poverty areas and children in moderate- and high-income neighborhoods (AOR: 3.20: 95% Cl: 1.62-6.29). CONCLUSION: The high prevalence of asthma among black children in poor neighborhoods is consistent with previous research on higher-than-average prevalence of childhood asthma in poor urban minority communities. Changing neighborhood social structures that contribute to racial disparities in asthma prevalence remains a challenge.     

Decreased markers of atopy in children with presumed early exposure to allergens, unhygienic conditions, and infections.

BACKGROUND: Several risk factors for the development of asthma and atopic disease in children have been described. Furthermore, there is consistent evidence that the prevalence of atopy increases with higher socioeconomic status. The knowledge about risk factors and preventive factors for atopy needs to be improved. OBJECTIVE: To compare 2 child populations (foster care and reference children) with different risk and protective factors for the development of atopy. METHODS: The study group consisted of 415 children, living in all 10 community foster homes in Lodz, a large industrial city in Poland. The study was performed from April 2, 2004, to April 30, 2006. The reference group consisted of 500 children, living with their parents at home, recruited from primary care centers. The primary outcome measures were skin prick test results and specific IgE in serum. Secondary outcomes included symptoms of allergic diseases and family history, including life conditions in early childhood. RESULTS: The full analysis set included 408 study children and 402 reference children. Significant differences were observed in the prevalence of atopy between the study and reference groups (11.3% vs 25.9%). We observed more positive skin prick test results in children from the reference group than in study children. To explain this phenomenon, we selected 16 variables that differ in both groups in early life and relate these to atopy. We found that the more cumulative features characteristic of the foster home population (poor living conditions), the lower the risk of atopy. CONCLUSION: Extremely unfavorable environmental circumstances, which are characteristic of the foster home population during early childhood, might prevent from atopy.     

Rural mental health: implications for telepsychiatry in clinical service, workforce development, and organizational capacity

In Hawai'i, rural residents suffer disproportionately from poor health and mental health outcomes. Hawai'i's island geography makes rural health service disparities especially compelling. Physician workforce shortages are projected to increase, despite 30 years of programs aimed at recruiting physicians to rural areas. Telepsychiatry has been shown to be a feasible way to provide a variety of health services to individuals living in rural areas with limited access to healthcare. The University of Hawai'i Rural Health Collaboration (UHRHC) was established by the Department of Psychiatry to address the need for workforce development and rural access to mental health services across the State of Hawai'i by using telepsychiatry. Partnerships with community health clinics have been formed to provide patient care and consultation-liaison services through telepsychiatry technology. In addition, UHRHC focuses on workforce development in its residency training curriculum by utilizing a service-learning approach to rural mental health. Evaluation of these efforts is currently underway, with preliminary evidence suggesting that UHRHC is a promising strategy to increase access to critical mental health services and reduce health disparities in rural Hawai'i.     

Risk factors for recurrent asthma hospital visits and death among a population of indigent older adults with asthma.

BACKGROUND: Little is known about the morbidity and mortality among older adults with asthma requiring hospital care. OBJECTIVES: To determine whether an initial hospital visit for asthma was associated with an increase in use of inhaled corticosteroids (CCS) at discharge, and to identify risk factors for recurrent asthma hospital visits and death. METHODS: A retrospective cohort analysis identified 93,174 persons 65 years and older enrolled in the Tennessee Medicaid program for at least 1 year and free of asthma hospital visits during that year; 510 survived a single hospital visit for asthma in 1992 and comprised the study population. Main outcome measures included recurrent hospital visit for asthma and all-cause mortality during the year after an asthma hospital visit. RESULTS: Among the 510 study subjects, 10% were on inhaled CCS at admission compared with 11% at discharge. Twenty-three percent of the population had recurrent asthma hospital visits and 12% died during 1-year followup. Asthma severity was the strongest independent risk factor for both a recurrent hospital visit [relative risk for moderate to severe disease 1.92 (1.01 to 3.66), and for near-fatal disease 2.28 (1.01 to 5.13), respectively] and death [relative risk for moderate to severe disease 2.99 (1.07 to 8.32) and for near-fatal disease 4.44 (1.34 to 4.69), respectively]. CONCLUSIONS: In this population, older adults with an exacerbation of asthma requiring hospital care experienced significant morbidity and mortality. An acute hospital visit for an asthma exacerbation did not result in initiation of inhaled CCS therapy. Asthma severity predicted both recurrent hospital visits and all-cause mortality among older adults with asthma requiring hospital care.     

Managing HIV/AIDS in correctional settings

Approximately one quarter of people living with HIV/AIDS in the United States pass through the correctional system, resulting in a burden of infection on the correctional health care system that has challenged correctional and public health officials. The HIV epidemic behind bars results from the high prevalence of HIV risk behaviors among those incarcerated: illicit drug use, untreated mental illness, prostitution, homelessness, and poverty. Challenges to HIV care in correctional settings include management of comorbid conditions, remoteness from HIV care sites, organizational constraints, and access to effective therapies. Despite these challenges, prisoners with HIV have derived considerable benefit from HIV detection and treatment. In order to achieve parity in HIV outcomes among vulnerable populations, effective prison-release programs that incorporate effective case management with effective drug treatment and adherence strategies are required to extend the benefit of highly active antiretroviral therapy as prisoners transition back to community settings.     

Asthma and academic performance in urban children

BackgroundUrban minority children experience high levels of asthma morbidity. Poor school performance can be an indicator that asthma is in poor control. Little attention has been paid to examining real-time links between asthma and academic performance, particularly in high-risk groups.ObjectiveExamine 1) academic performance across a range of indicators in a group of urban children with asthma and urban children without chronic illness and ethnic differences in these associations, and 2) associations between asthma and academic performance in the group of urban children with asthma and ethnic differences in these associations.MethodsTwo hundred sixteen black/African American (33%), Latino (46%), and non-Latino white (21%) urban children, ages 7 to 9 years completed a clinic- and home-based protocol that assessed asthma and allergy status, objective measurements of lung function, and academic functioning.ResultsAnalyses revealed that children with asthma experienced a higher number of school absences when compared with healthy controls. Greater disparities in academic outcomes emerged when examining ethnic differences within the groups of children with and without asthma. Poor academic outcomes were observed in Latino children with asthma. Furthermore, a strong correspondence of poor asthma outcomes and decrements in academic performance were seen in the full sample, and these associations emerged across ethnic groups.ConclusionAsthma activity contributes to poorer academic outcomes across a range of indicators, and urban minority children with asthma, particularly Latino children, may be at heightened risk for poorer academic performance. School management guidelines for asthma need to be consistently implemented and tailored for school staff, caregivers, and students with asthma to address challenges of managing asthma within the urban school setting.     

Should patients with persistent severe asthma be monitored for medication adherence?

BACKGROUND: Poor asthma outcomes often result from patients not following physician medication recommendations (ie, nonadherence). Estimates suggest that 50% of patients with asthma do not follow physician medication recommendations. OBJECTIVE: To examine the rationale for making available objective medication adherence monitors for physicians to improve the quality of care for patients with severe persistent asthma. METHODS: Review of the literature was undertaken in the following areas related to asthma: cost, morbidity, adherence, adherence monitoring, outcomes, and guidelines. RESULTS: Patients with severe asthma are at risk for nonadherence because of (1) the use of multiple medications to control symptoms, (2) coexisting disease states, (3) the occurrence of depression and anxiety, and (4) the high cost of care. Research studies have demonstrated the effectiveness of objective monitoring as part of multiple clinical strategies to improve adherence and reduce morbidity and the cost of asthma care. Without objective adherence monitoring, physicians may not accurately assess nonadherence as the cause of treatment failure. This may lead to inappropriate increases in therapy, diagnostic studies, and consultations and may leave the patient at risk for persistent symptoms, morbidity, and death. CONCLUSION: By correctly assessing nonadherence as the cause of treatment failure in patients with not only severe asthma but mild and moderate disease as well, practicing physicians may improve the quality of care provided.     

Case Management Interventions for HIV-Infected Individuals

Engagement of HIV-positive persons into care and achieving optimal antiretroviral treatment outcomes is a fundamental HIV prevention strategy. Case management model was recommended as a beneficial model of care for patients with a new HIV diagnosis, focusing on individuals with unmet needs, and linking them with the coordinated health and social services to achieve desired outcomes. HIV case management is population-driven and programs are designed to respond to the unique needs of the client population they serve, such as substance users, homeless, youth, and prison inmates. This view found 28 studies addressing effectiveness and impacts of case management intervention for people living with or at risk of HIV/AIDS. Effectiveness of case management intervention was categorized as follows: decreased mortality and improve health outcomes, linkage to and retention in care, decreased unmet needs, and reducing risky behaviors.     

Adult asthma prevalence, morbidity and mortality and their relationships with environmental and medical care factors in Singapore

We have conducted a series of studies on adult asthma in Singapore that describe the prevalence, morbidity and mortality and their relationships with environmental and medical care factors. There was no evidence of a temporal increase of mortality from 1976 to 1995 for adults. The prevalence rate of asthma is 2.4% in men and 2.0% in women. There is considerable morbidity among asthmatics, corticosteroids are under-used, and patients' knowledge and self-management skills is poor. Increased morbidity is significantly associated with current keeping of pets, current smoking, and the patients' knowledge and self-management skills. Occupational exposure contributes up to a third of asthma morbidity. Malays and Indians have higher rates of asthma mortality and morbidity than Chinese. They have greater exposures to airborne allergens from keeping rugs or carpets, and pets. Malays experience the most morbidity from asthma, but make less use of health services, and receive less medical attention, than Indians or Chinese.