Chronic stress exposure among young African American children with asthma: Racism is a factor

Research Priorities in Pediatric Asthma Morbidity: Addressing the Impacts of Systemic Racism on Children with Asthma in the United States. An Official American Thoracic Society Workshop Report

Background: In the United States, Black and Latino children with asthma are more likely than White children with asthma to require emergency department visits or hospitalizations because of an asthma exacerbation. Although many cite patient-level socioeconomic status and access to health care as primary drivers of disparities, there is an emerging focus on a major root cause of disparities-systemic racism. Current conceptual models of asthma disparities depict the historical and current effects of systemic racism as the foundation for unequal exposures to social determinants of health, environmental exposures, epigenetic factors, and differential healthcare access and quality. These ultimately lead to biologic changes over the life course resulting in asthma morbidity and mortality. Methods: At the 2022 American Thoracic Society International Conference, a diverse panel of experts was assembled to identify gaps and opportunities to address systemic racism in childhood asthma research. Panelists found that to examine and address the impacts of systemic racism on children with asthma, researchers and medical systems that support biomedical research will need to 1) address the current gaps in our understanding of how to conceptualize and characterize the impacts of systemic racism on child health, 2) design research studies that leverage diverse disciplines and engage the communities affected by systemic racism in identifying and designing studies to evaluate interventions that address the racialized system that contributes to disparities in asthma health outcomes, and 3) address funding mechanisms and institutional research practices that will be needed to promote antiracism practices in research and its dissemination. Results: A thorough literature review and expert opinion discussion demonstrated that there are few studies in childhood asthma that identify systemic racism as a root cause of many of the disparities seen in children with asthma. Community engagement and participation in research studies is essential to design interventions to address the racialized system in which patients and families live. Dissemination and implementation studies with an equity lens will provide the multilevel evaluations required to understand the impacts of interventions to address systemic racism and the downstream impacts. To address the impacts of systemic racism and childhood asthma, there needs to be increased training for research teams, funding for studies addressing research that evaluates the impacts of racism, funding for diverse and multidisciplinary research teams including community members, and institutional and financial support of advocating for policy changes based on study findings. Conclusions: Innovative study design, new tools to identify the impacts of systemic racism, community engagement, and improved infrastructure and funding are all needed to support research that will address impacts of systemic racism on childhood asthma outcomes.

Disparities in adolescent controller medication adherence, treatment barriers, and asthma control

BACKGROUND

Disparities in asthma persist despite advances in interventions. Adherence and self-management behaviors are critical yet challenging during adolescence. Treatment barriers include individual factors as well as structural and social determinants of health.

OBJECTIVE

To determine differences in controller medication adherence, asthma control, and treatment barriers by race, income, and insurance and whether racial disparities persist when controlling for income and insurance. Associations between adherence, barriers, and control were also examined.

METHODS

Adolescents completed measures of treatment barriers and asthma control. Controller medication adherence was measured electronically. Descriptive statistics, means comparisons, and analyses of covariance were conducted.

RESULTS

One hundred twenty-five adolescents participated (Mage = 14.55, SD = 2.01, 37.6% Black or African American, 55.2% White). Black or African American adolescents had significantly lower adherence than White adolescents, t(105) = 2.79, p = .006, Cohen's d = .55. This difference was not significant when controlling for income and insurance (p > .05). There was a significant difference in asthma control, F(1,86) = 4.07, p = .047, ηp 2 = .045, where Black or African American adolescents had better asthma control scores than White adolescents. Feeling tired of living with asthma was the most common barrier among all adolescents (62.4%). More Black or African American adolescents endorsed difficulty getting to the pharmacy than White adolescents, X2 (1, N = 116) = 4.86, p = .027.

CONCLUSIONS

Racial disparities in asthma may be partially driven by income, insurance, and pharmacy access. Asthma burnout may be important to address for all adolescents with asthma.

Sources of Stress and Coping Strategies Among Urban African American Adolescents: A Qualitative Study of Child and Caregiver Perspectives

Early adolescence is a critical point for intervention to protect against negative consequences of stress on the developing brain. This study aimed to gather perspectives on stress from adolescents and their caregivers living in under-resourced Baltimore City neighborhoods. Nine African American adolescents and their caregivers (n = 18 total) participated in qualitative interviews exploring neighborhood environments, sources of stress, and coping behaviors. Neighborhood social cohesion was described as a strength of participants' communities, despite concerns about neighborhood safety. Caregivers were highly aware of their child's stressors and coping behaviors. School-related pressure was a prevalent source of stress emphasized by adolescents, along with social stress due to disrupted routines during the COVID-19 pandemic. Adolescents described frequent use of electronics to cope with stress, as well as self-care and relaxation techniques. Themes identified from these data can be used to inform future adolescent stress-reduction interventions and stress-prevention efforts in this priority population.

Toward a new model of childhood asthma care: community needs assessment in an underserved urban population

OBJECTIVES

The objective of this study was to utilize a community-engaged research approach to better understand gaps and opportunities for improving asthma care from the perspectives of patients, caregivers, community organization representatives, and healthcare providers in a predominantly minority community.

METHODS

Forty-one participants from four groups (patients, caregivers, community organization representatives, healthcare providers) participated in interviews or focus groups. A phenomenological approach to this qualitative research allowed the research team to better understand the lived experiences of families seeking asthma care in this community.

RESULTS

Five gaps and five corresponding opportunities were identified. The gaps identified were unequal healthcare resource distribution; underrepresentation of health professionals from diverse backgrounds; experiences of environmental racism; mistrust, bias, and discrimination in healthcare encounters; and systemic marginalization of communities. The opportunities identified include increasing healthcare infrastructure and accessibility; increasing racially, culturally, and linguistically congruent healthcare; implementing equitable improvements to the built environment; building relationships with communities and individuals; and acknowledging communities' strengths and resilience.

CONCLUSION

This study identified systemic gaps to asthma care that are of prominent concern to the community.

Social Risks and Health Care Utilization Among a National Sample of Children With Asthma

OBJECTIVES

Prior studies using single-center populations have established associations between social risks and health care utilization among children with asthma. We aimed to evaluate associations between social risks and health care utilization among a nationally representative sample of children with asthma.

STUDY DESIGN

In this cross-sectional study, we utilized the 2018-2019 National Survey of Children's Health to identify children 2 to 17 years old with asthma. Using the Healthy People (HP) 2030 social determinants of health (SDOH) framework, we identified 31 survey items assessing 18 caregiver-identified social risks as exposure variables and classified them into the 5 HP SDOH domains (Economy, Education, Health care, Community, and Environment). Primary outcome was caregiver-reported health care utilization. Associations between individual social risks and total number of SDOH domains experienced with health care utilization were assessed.

RESULTS

The weighted study population included 8.05 million children, 96% of whom reported ≥1 social risk. Fourteen social risks, spanning all 5 SDOH domains, were significantly associated with increased health care utilization. The 3 risks with the highest adjusted odds ratios (aOR) of health care utilization included: experiencing discrimination (aOR 3.26 [95% confidence interval (CI): 1.75, 6.08]); receiving free/reduced lunch (aOR 2.16, [95% CI 1.57, 2.98]); and being a victim of violence (aOR 2.11, [95% CI 1.11, 4]). Children with risks across more SDOH domains reported significantly higher health care utilization.

CONCLUSIONS

Among our national population of children with asthma, social risks are prevalent and associated with increased health care utilization, highlighting their potential contribution to pediatric asthma morbidity.

The influence of urban exposures and residence on childhood asthma

Children with asthma who live in urban neighborhoods experience a disproportionately high asthma burden, with increased incident asthma and increased asthma symptoms, exacerbations, and acute visits and hospitalizations for asthma. There are multiple urban exposures that contribute to pediatric asthma morbidity, including exposure to pest allergens, mold, endotoxin, and indoor and outdoor air pollution. Children living in urban neighborhoods also experience inequities in social determinants of health, such as increased poverty, substandard housing quality, increased rates of obesity, and increased chronic stress. These disparities then in turn can increase the risk of urban exposures and compound asthma morbidity as poor housing repair is a risk factor for pest infestation and mold exposure and poverty is a risk factor for exposure to air pollution. Environmental interventions to reduce in-home allergen concentrations have yielded inconsistent results. Population-level interventions including smoking bans in public places and legislation to decrease traffic-related air pollution have been successful at reducing asthma morbidity and improving lung function growth. Given the interface and synergy between urban exposures and social determinants of health, it is likely population and community-level changes will be needed to decrease the excess asthma burden in children living in urban neighborhoods.

Racial Disparities in Medication Adherence Barriers: Pediatric Epilepsy as an Exemplar

OBJECTIVE

To evaluate how racial disparities in medication adherence barriers relate to key clinical outcomes (i.e., seizure control and adherence) in pediatric epilepsy and to identify the most critical barriers in determining health outcomes in Black youth and White youth.

METHODS

This observational study included a sample of youth aged 2-17 years with epilepsy obtained by combining data from four different studies. A total of 226 caregivers and 43 adolescents reported on adherence barriers. An electronic monitor was used to measure adherence to the primary antiepileptic drug. Racial disparities in individual barriers were examined. The relative importance of different types of barriers in determining clinical outcomes was evaluated in both Black and White youth.

RESULTS

Adherence barriers, including running out of medications, access to pharmacies, competing demands, and difficulty swallowing, disproportionally affected Black children with epilepsy compared to White children. System- and community-level barriers emerged as the most important in determining seizure outcomes among Black youth. Both system- and individual-level barriers, on the other hand, were important for adherence outcomes.

CONCLUSIONS

System- and community-level barriers, as opposed to individual-level barriers, are more highly endorsed by Black families compared to White families. These barriers are also the most critical in driving seizure outcomes among Black youth. There is a critical need to shift from a primary focus on individual-level barriers to an approach that deliberately targets larger systemic barriers to reduce the existing adherence and health disparities that affect Black children with pediatric conditions.

Asthma and the social determinants of health

OBJECTIVE

To synthesize the growing body of literature on the role of social determinants of health (SDoH) in asthma and asthma disparities.

DATA SOURCES

A pubmed.gov search was performed to identify published literature on SDoH, asthma, asthma disparities, and race and ethnicity. Current asthma statistics of the Centers for Disease Control and Prevention were reviewed.

STUDY SELECTIONS

Relevant articles on SDoH, asthma, asthma disparities, and race and ethnicity were reviewed in detail.

RESULTS

Black and Latinx Americans have a higher asthma prevalence and greater asthma morbidity than White Americans and also bear a disproportionate burden of SDoH. Inequities in SDoH are rooted in structural racism and population-level injustices that affect the socioeconomic status, physical environment, and health care access/quality of Black and Latinx Americans. There is evidence that racial/ethnic inequities in SDoH, such as socioeconomic status, neighborhood environment, housing, environmental exposures, and health care access/quality, contribute to excess burden of asthma prevalence/incidence, morbidity, exacerbations, and abnormal lung function among certain racial/ethnic populations. In addition, Black and Latinx communities experience high levels of long-term stress, which may increase asthma risk through direct effects on the immune system and hypothalamic-pituitary-adrenocortical activation. Long-term stress may also mediate the effects of SDoH on asthma.

CONCLUSION

Although there is clear evidence linking SDoH to excess asthma risk and implicating SDoH in asthma disparities, the extent to which asthma disparities are explained by inequities in SDoH and the relative contributions of each of these SDoH to asthma disparities remain unclear. This knowledge is needed to effectively develop and test systems-level interventions targeting SDoH, with the ultimate goal of meaningfully reducing racial/ethnic asthma disparities.

Revealing the racial and spatial disparity in pediatric asthma: A Kansas City case study

Black and other socially disadvantaged children are disproportionately burdened by high rates of pediatric asthma. Intraurban variation in environmental risk factors and limited access to high-resolution health data make it difficult to identify vulnerable patients, communities, or the immediate exposures that may contribute to pediatric asthma exacerbation. This article presents a novel, interdisciplinary health disparities research and intervention strategy applied to the problem of pediatric asthma in Kansas City. First, address-level electronic health records from a major children's hospital in the Kansas City region are used to map the distribution of asthma encounters in 2012 at a high spatial resolution. Census tract Environmental Justice Screening Method (EJSM) indicators are then developed to scan for patterns in both the population health risks and vulnerabilities that may contribute to the burden of asthma in different communities. A Bayesian Profile Regression cluster analysis is used to systematically explore the complex relationships between census tract EJSM indicators and pediatric asthma incidence rates, helping to identify population characteristics and risk factors associated with both high and low rates of pediatric asthma throughout the region. The EJSM scanning exercise and BPR analysis demonstrate that each community faces a distinct set of risks and vulnerabilities that can contribute to the rate of acute pediatric asthma acute care encounters, providing targets for research and intervention. It is clear, however, that different forms of social disadvantage are driving high rates of pediatric asthma, which is closely tied to uneven development patterns and racial residential segregation. The results provide a starting point for designing place-based health disparities research and intervention strategies catered to the unique needs of vulnerable patients and communities; disparities-focused research and intervention strategies that leverage local knowledge and resources through community-based practices.

Intergenerational Impacts of Maternal Stress on Early Childhood Atopy in Black Americans

OBJECTIVE

Black children are disproportionately affected by atopic diseases (i.e., atopic dermatitis, allergic rhinitis, asthma, and food allergies), with health disparities present in early life. Studies in White samples suggest that maternal stress confers risk for offspring atopy, yet little is known about these relationships in Black populations. This study seeks to (a) examine the relationship between self-reported and physiological indicators of maternal stress and offspring atopy and (b) explore warm and responsive caregiving as a potential protective factor in Black Americans.

METHODS

A sample of 179 Black mother-child dyads of varying socioeconomic status participated in a prospective longitudinal study. Mothers completed self-reports of childhood trauma, prenatal stress, postnatal stress, and physician diagnosis of offspring atopy; provided blood samples to assess physiological responses to chronic stress exposure; and participated in a behavioral task with their infant.

RESULTS

Maternal self-reports of childhood trauma, prenatal stress, and postnatal stress were not associated with offspring diagnosis of atopy by 2-3 years of age. Mothers who produced a smaller inflammatory response during pregnancy were more likely to have an offspring with atopy by 2-3 years of age. Warm and responsive parenting demonstrated a protective effect; the positive association between maternal stress and offspring atopy was less apparent in cases of mother-child interactions characterized by high levels warm and responsive parenting.

CONCLUSION

Failure to replicate previous findings suggests that the maternal stress-offspring atopy relationship is complex. Future studies must examine the unique stressors in Black Americans, as well as caregiving as a potential protective factor.

Socioeconomic and Racial and/or Ethnic Disparities in Multisystem Inflammatory Syndrome

OBJECTIVES

To characterize the socioeconomic and racial and/or ethnic disparities impacting the diagnosis and outcomes of multisystem inflammatory syndrome in children (MIS-C).

METHODS

This multicenter retrospective case-control study was conducted at 3 academic centers from January 1 to September 1, 2020. Children with MIS-C were compared with 5 control groups: children with coronavirus disease 2019, children evaluated for MIS-C who did not meet case patient criteria, children hospitalized with febrile illness, children with Kawasaki disease, and children in Massachusetts based on US census data. Neighborhood socioeconomic status (SES) and social vulnerability index (SVI) were measured via a census-based scoring system. Multivariable logistic regression was used to examine associations between SES, SVI, race and ethnicity, and MIS-C diagnosis and clinical severity as outcomes.

RESULTS

Among 43 patients with MIS-C, 19 (44%) were Hispanic, 11 (26%) were Black, and 12 (28%) were white; 22 (51%) were in the lowest quartile SES, and 23 (53%) were in the highest quartile SVI. SES and SVI were similar between patients with MIS-C and coronavirus disease 2019. In multivariable analysis, lowest SES quartile (odds ratio 2.2 [95% confidence interval 1.1-4.4]), highest SVI quartile (odds ratio 2.8 [95% confidence interval 1.5-5.1]), and racial and/or ethnic minority background were associated with MIS-C diagnosis. Neither SES, SVI, race, nor ethnicity were associated with disease severity.

CONCLUSIONS

Lower SES or higher SVI, Hispanic ethnicity, and Black race independently increased risk for MIS-C. Additional studies are required to target interventions to improve health equity for children.

The Association of Asthma, Sexual Identity, and Inhaled Substance Use among U.S. Adolescents

Rationale: Minority sexual identity appears to confer asthma risks. Although associations between inhaled substances and asthma are established, these have not been examined among sexual minority youths. Given sexual minority adolescents' disproportionately high rates of substance use, research is needed to fill this important gap.Objectives: Using a representative sample of adolescents from the United States, we 1) examined associations among asthma, sexual identity, and inhaled substance use and tested 2a) whether sexual identity moderates relationships between asthma and inhaled substance use and 2b) whether inhaled substance use mediates associations between sexual identity and asthma.Methods: Data are from the 2015 and 2017 Youth Risk Behavior Surveillance Survey. Adolescents (n = 30,113) reported if they were ever diagnosed with asthma, current use of cigarettes, cigars and/or cigarillos, marijuana, and electronic vapor products and if they ever used inhalants or synthetic marijuana. We used logistic regression to examine associations between asthma, sexual identity, and inhaled substance use controlling for age, race or ethnicity, and body mass index percentile, stratified by sex.Results: Lesbian, gay, and bisexual respondents had higher relative risks for asthma than heterosexual youth. Sexual minority female youths had significantly higher relative risks than heterosexual female youths for use of every inhaled substance. There were few sexual identity differences in inhaled substance use among male youths. Inhaled substance use was significantly associated with higher risks for asthma. In general, associations between each individual inhaled substance and asthma did not differ between sexual minority and heterosexual youths. However, when all inhaled substances were added into the models concurrently, inhaled substance use appeared to mediate associations with asthma among lesbian and bisexual female youths, and partially mediated these associations among sexual minority male youths.Conclusions: Sexual identity and inhaled substance use appear to play important roles in asthma risk. However, these variables do not fully explain the risk, suggesting that other unmeasured variables (e.g., stress and victimization) may be implicated in risks for both inhaled substance use and asthma. It is important that clinicians providing care to adolescents ask about sexual identity and inhaled substance use. Effective approaches to reducing inhaled substance use among adolescents, especially sexual minorities, are needed.