Asthma disparities in the prevalence, morbidity, and treatment of Latino children
Introduction
Substantial evidence has documented how pediatric ethnic and racial disparities exist in the quality of treatment, access to services, prevention and management of asthma (Center for Disease Control and Prevention (CDC), 2004; Institute of Medicine (IOM), 2002). Asthma is the most prevalent childhood chronic illness in the US and African American children and adolescents (referred to as children in the text) appear to have the highest asthma burden (Akinbami & Schoendorf, 2002). However, results of the National Health Interview Survey (NHIS) showed that when Latinos are disaggregated into different subgroups, Puerto Rican children have the highest rates (Lara, Akinbami, Flores, & Morgenstern, 2006).
Numerous factors have been implicated in explaining asthma disparities among minority children, yet the mechanisms accounting for these disparities are poorly understood. This paper reviews the existing published research related to asthma disparities, and frames the results within a conceptual model in order to explain these disparities. We start by documenting asthma disparities as they are reflected in the outcomes of asthma (i.e., prevalence, morbidity, severity), as well as in the process of care (i.e., access and quality of treatment) received by Latino children. We review findings of differences between ethnic groups and within Latino subgroups, which can often account for these disparities. We end with suggestions for future research examining the determinants of asthma disparities.
Section snippets
A conceptual model for pediatric asthma disparities
A conceptual framework to understand asthma disparity can be useful to clinicians, stakeholders, and researchers who strive to improve service access, quality, and outcomes of care for Latino children with asthma of different ethnic subgroups (herein referred to as “Latino children”). Health disparities in health care have been defined as “racial or ethnic differences in the quality of health care that are due to access-related factors or clinical needs, preferences, and appropriateness of
Genetic and biological factors
Ethnic subgroup differences in the prevalence of asthma may be in part explained by genetic or biological differences that place certain groups at greater risk for asthma. Others have hypothesized that the higher prevalence of asthma among Puerto Ricans may be related to a genetic or biologic predisposition to asthma, in interaction with environmental factors (i.e., social and environmental risks; Lara, Morgenstern, Duan, & Brook, 1999).
Research on the genetics of asthma has progressed rapidly.
Cultural beliefs and medication behaviors
Patient behaviors may be the result of disparities in the other components of our model (e.g., poor patient/provider communication), so that patient variables in isolation are also unlikely to be the overriding source of disparities.
Nevertheless, family beliefs about asthma can shape views about how to use services, what to expect of the medical encounter, and patterns of symptom reporting (Guarnaccia, Pelto, & Schensul, 1985). Cultural beliefs and the use of home remedies can delay timely
Indoor/outdoor allergens and pollution
Similar to other minority groups, Latinos have high rates of low-income status relative to the majority group. As a result, many families live in poor neighborhoods where they are more likely to be exposed to indoor and outdoor pollutants. Specifically, the presence of environmental tobacco smoke is more common in urban, low-income homes (Kattan et al., 2005). Housing in low-income neighborhoods is also more likely to have poor ventilation and to have water leaks that allow a higher
Health-care system
As depicted in our model, the individual differences that characterize children and families, and the context within which they reside can affect how children and families are both received by and interact with the health-care system. Our review now focuses on health-care system factors, including the process of care (e.g., access and quality of care), which may predict disparities in asthma outcomes.
Insurance coverage
There is evidence that insurance coverage is a predictor of access to health care for the diagnosis and treatment of asthma, and avoidable hospitalizations, particularly among the poor (Flores, Abreu, Chaisson, & Sun, 2003). But for most Latino families, accessing care appears to be a major problem because of lack of health insurance. A literature review of insurance coverage (Zambrana & Carter-Pokras, 2004) documents that Latino children from all ethnic subgroups are less likely to be insured
Work force diversity, work overload
Challenges related to the operation of the health care and provider organization system may contribute to asthma disparities. Minority physicians represent only 9% of all physicians in the US and of these, 24.9% are Latino (Association of American Medical Colleges (AAMC), 2000). It is not surprising that unless a provider organization makes an effort to attract a diverse workforce, few Latino physicians may be available to treat Latino children. The majority of Latinos lack a usual source of
Training, stereotyping, beliefs of providers
There is evidence that Latino children are less likely to be seen by an asthma specialist and are more likely to be seen by a provider who is not board certified (Ortega et al., 2001; Shields et al., 2004). This may result in treatment disparities, as asthma specialists are more likely to follow asthma guidelines, to prescribe anti-inflammatory agents independent of minority status, and to have higher rates of patient satisfaction than generalists (Finkelstein et al., 2002; Legorreta et al.,
Conclusions: clinical and policy implications
Mainland and island Puerto Rican children have higher rates of parental reports of diagnosed asthma and mortality than any other ethnic or racial group in the US, while Mexican American children have the lowest rates. To date we do not know why this is so, even though Mexican Americans are as poor or poorer than island Puerto Ricans, and have less access to care than their Puerto Rican counterparts. Genetic or biological predispositions in interaction with many different environmental factors
Future directions for research
The existing research on asthma disparities has made great strides in furthering our understanding of potential determinants of health outcomes. Studies should assess the extent to which each of the factors alone and interacting with other factors depicted in our model contribute to asthma disparities. These studies should attempt to disaggregate the different Latino subgroups and should quantify the strengths of Latino families and their unique characteristics and experiences that may
Acknowledgments
We would like to acknowledge the following investigators: Drs. Vivian E. Febo, Jesús Soto, Angel Colón, José Rodríguez-Santana, Federico Montealegre, María Alvarez, and Rosa Pérez-Perdomo. Financial support for this study was obtained from U01 HL 072519-01 Canino (PI) and R01 HL45157 Fritz (PI) from the National Heart, Lung and Blood Institute; MH 59876-02 Alegría (PI) from the National Institute of Mental Health; P20 MD 000537-01 Canino (PI) from the National Center for Minority Health
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