Reviews and feature article
Addressing asthma health disparities: A multilevel challenge

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Substantial research has documented pervasive disparities in the prevalence, severity, and morbidity of asthma among minority populations compared with non-Latino white subjects. The underlying causes of these disparities are not well understood, and as a result, the leverage points to address them remain unclear. A multilevel framework for integrating research in asthma health disparities is proposed to advance both future research and clinical practice. The components of the proposed model include health care policies and regulations, operation of the health care system, provider/clinician-level factors, social/environmental factors, and individual/family attitudes and behaviors. The body of research suggests that asthma disparities have multiple, complex, and interrelated sources. Disparities occur when individual, environmental, health system, and provider factors interact with one another over time. Given that the causes of asthma disparities are complex and multilevel, clinical strategies to address these disparities must therefore be comparably multilevel and target many aspects of asthma care. Several strategies that could be applied in clinical settings to reduce asthma disparities are described, including the need for routine assessment of the patient's beliefs, financial barriers to disease management, and health literacy and the provision of cultural competence training and communication skills to health care provider groups.

Section snippets

Health care policy factors

There is evidence that certain health care policies might contribute to disparities in asthma outcomes and that cost-control strategies implemented by public health plans might differentially affect minority populations. Minorities are overrepresented in government-sponsored health plans, such as Medicare, which are federally and state regulated for cost control. As a result, minority populations might receive restricted access to specialists and preventive care, thus resulting in lower quality

Adherence with guidelines

National guidelines23 continue to stress that families and health care providers should collaborate actively to manage asthma, with an emphasis on preventive management. Preventive management includes strategies to avert asthma episodes through control of relevant environmental triggers, regular use of controller medications for patients with persistent symptoms, use of an asthma action plan, and referrals to specialists when indicated. In addition, assessment of asthma severity at initial

Health provider/clinician factors

Although less commonly studied, it should be acknowledged that individual provider characteristics and beliefs have the potential to contribute to disparities in asthma outcomes. The Institute of Medicine report17 proposes that although most providers intend to provide equitable care, subtle forms of discrimination might contribute to disparities in health care. The report proposes 3 mechanisms that might produce discriminatory provider practices: unintentional bias against minorities in

Individual/family factors

Emerging research has examined the role that biologic and genetic risk factors might play in asthma disparities.43, 44 Although these inherent risk factors likely contribute to susceptibility, severity, or both, it is also clear that substantial variation in asthma outcomes might be mediated through the influence of individual behavioral and psychosocial differences on self-management. We describe below these potentially modifiable individual/family factors that might contribute to asthma

Social/environmental factors

Americans with low SES, whether measured based on income or occupation, have higher levels of illness than higher-income populations.63 Persons with low incomes in general have poorer health and shorter life expectancy.64 For certain racial groups, such as African Americans, mortality rates in almost every illness, including asthma, are higher than those seen in whites independent of income level.63 Furthermore, minorities and individuals with low SES are more likely to engage in high-risk

Multilevel conceptual model for explaining and addressing asthma disparities

The body of research in this area suggests that no single risk factor has emerged as the primary cause of disparities. Instead, asthma disparities have multiple, complex, and interrelated sources. Therefore to move forward in our understanding of asthma disparities and development of effective interventions, it will be necessary to frame our future research within a conceptual model that incorporates a range of risk factors at multiple levels of influence.

We propose a multilevel, multifaceted

Practical implications of applying a multilevel asthma disparities model for research and clinical practice

It is apparent from this review that understanding ethnic disparities, cultural disparities, or both in asthma morbidity and prevalence is a complicated process. Although multiple risk factors have been identified, no single variable directly accounts for large differences in outcomes. If we are to reduce asthma disparities, there is a need to obtain a better understanding of the complex ways in which multiple variables interact and the relative weight that each one contributes to inequalities

Clinical implications and recommendations

Our review of the literature and proposed model underscores that the causes of asthma disparities are complex and multilevel. Clinical strategies to address these disparities must therefore be comparably multilevel and targeted. We believe that disparities occur when individual, environmental, health system, and provider factors interact with each other in multiple ways and that these interactions can vary according to the person's particular needs that change with time. With this preamble in

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    (Supported by an educational grant from Merck & Co., Inc.)

    Series editors: Joshua A. Boyce, MD, Fred Finkelman, MD, William T. Shearer, MD, PhD, and Donata Vercelli, MD

    Supported by National Institutes of Health grant no. 5P60 MD002261-02 funded by the National Center for Minority Health and Health Disparities and 5 U01 HL 072519-05 Canino (PI) and U01 HL 072438 Fritz (PI) from the National Heart, Lung, and Blood Institute.

    Terms in boldface and italics are defined in the glossary on page 1210.

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