Time's up to adopt a biopsychosocial model to address racial and ethnic disparities in asthma outcomes

Exploring the relationship between school-supervised asthma therapy and social determinants of health in pediatric asthma care

BACKGROUND

Social determinants of health (SDoH), including access to care, economic stability, neighborhood factors, and social context, strongly influence pediatric asthma outcomes. School-supervised asthma therapy (SST) is an evidence-based strategy that improves asthma outcomes, particularly for historically marginalized children, by providing support for daily medication adherence in school. However, little is known about the relationship between these programs and the adverse SDoH commonly affecting underrepresented minority and marginalized children with asthma.

METHODS

We examined qualitative data from interviews (n = 52) conducted between 2017 and 2020 with diverse multi-level partners involved in Asthma Link, a SST intervention. Participants included end-users (children and their parents), deliverers (school nurses and pediatric providers), and systems-level partners (e.g., insurers, legislators, and state officials). We used inductive coding to determine themes and subthemes and deductive coding using the Healthy People 2030 SDoH framework.

RESULTS

Three themes emerged: (1) SST mitigates adverse SDoH (improves access to preventive healthcare and asthma health literacy), (2) SST benefits children experiencing specific adverse SDoH (provides a consistent medication routine to children with unstable family/housing situations) and (3) specific adverse SDoH impede SST implementation (economic instability, culture and language barriers).

CONCLUSION

This study suggests an important relationship between SDoH and SST that warrants further evaluation in our future work on this community-based asthma intervention. Moreover, our findings underscore the importance of measuring SDoH in the implementation and evaluation of pediatric asthma interventions, particularly given the strong influence of these social factors on child health outcomes.

Socioeconomic status, diet, and recurrent severe asthma exacerbations in Puerto Rican youth

Background

Why Puerto Rican youths have higher rates of severe asthma exacerbations (SAEs) than their non-Hispanic White peers is unclear.

Objective

We aimed to identify risk factors associated with recurrent SAEs in Puerto Rican youths with asthma.

Methods

We performed cross-sectional and longitudinal analyses of recurrent SAEs in 209 Puerto Rican youths with asthma who participated in 2 cross-sectional studies approximately 5.2 years apart: the Puerto Rico Genetics of Asthma and Lifestyle study (visit 1, participants aged 6-14 years) and the Epigenetic Variation and Childhood Asthma in Puerto Ricans study (visit 2, participants aged 9-20 years). Recurrent SAEs were defined as at least 2 SAEs in the previous year.

Results

Of the youths in our study, there were 80 (38.3%) and 47 (22.4%) with recurrent SAEs at visit 1 and visit 2, respectively, and 31 participants (14.8%) had persistent recurrent SAEs (ie, recurrent SAEs at both visits). In multivariable analyses, low household income was significantly associated with 2.4 to 12.3 times increased odds of recurrent SAEs in all analyses, with stronger longitudinal associations. Low parental education level, nonprivate or employer-based health insurance, overweight or obesity, residential proximity to a major road, and low or moderate level of outdoor activity were each significantly associated with recurrent SAEs in at least 1 analysis. Further, persistence of low parental numeracy level, low household income, and an unhealthy diet were each associated with persistent recurrent SAEs.

Conclusion

In this study of Puerto Rican youths with asthma, persistence of low parental numeracy level, a low household income, and an unhealthy diet were associated with persistent recurrent SAEs. Our findings support policies promoting equity and healthy lifestyles for Puerto Rican children and their families.

Lower socioeconomic status may help explain racial disparities in asthma and atopic dermatitis prevalence: A mediation analysis

BACKGROUND

Racial disparities in atopic disease (atopic dermatitis [AD], asthma, and allergies) prevalence are well documented. Despite strong associations between race and socioeconomic deprivation in the United States, and socioeconomic status (SES) and atopic diseases, the extent to which SES explains these disparities is not fully understood.

OBJECTIVE

We sought to identify racial disparities in childhood atopic disease prevalence and determine what proportion of those disparities is mediated by SES.

METHODS

This study used the National Health Interview Survey (2011-2018) to investigate AD, asthma, and respiratory allergy prevalence in Black and White children and the extent to which measures of SES explain any identified disparities.

RESULTS

By race, prevalences were as follows: AD, White 11.8% (95% CI: 11.4%, 12.2%) and Black 17.4% (95% CI: 16.6%, 18.3%); asthma prevalence, White 7.4% (95% CI: 7.0%, 7.7%) and Black 14.3% (95% CI: 13.5%, 15.0%); respiratory allergy, White 11.4% (95% CI: 11.0%, 11.9%) and Black 10.9% (95% CI: 10.3%, 11.6%). The percentage of the disparity between racial groups and disease prevalence explained by a multivariable measure of SES was 25% (95% CI: 15%, 36%) for Black versus White children with AD and 47% (95% CI: 40%, 54%) for Black versus White children with asthma.

CONCLUSIONS

In a nationally representative US population, Black children had higher prevalence of AD and asthma than White children did and similar prevalence of respiratory allergy; a multivariable SES measure explained a proportion of the association between Black versus White race and AD and a much larger proportion for asthma.

Incidence rates of childhood asthma with recurrent exacerbations in the US Environmental influences on Child Health Outcomes (ECHO) program

BACKGROUND

Descriptive epidemiological data on incidence rates (IRs) of asthma with recurrent exacerbations (ARE) are sparse.

OBJECTIVES

This study hypothesized that IRs for ARE would vary by time, geography, age, and race and ethnicity, irrespective of parental asthma history.

METHODS

The investigators leveraged data from 17,246 children born after 1990 enrolled in 59 US with 1 Puerto Rican cohort in the Environmental Influences on Child Health Outcomes (ECHO) consortium to estimate IRs for ARE.

RESULTS

The overall crude IR for ARE was 6.07 per 1000 person-years (95% CI: 5.63-6.51) and was highest for children aged 2-4 years, for Hispanic Black and non-Hispanic Black children, and for those with a parental history of asthma. ARE IRs were higher for 2- to 4-year-olds in each race and ethnicity category and for both sexes. Multivariable analysis confirmed higher adjusted ARE IRs (aIRRs) for children born 2000-2009 compared with those born 1990-1999 and 2010-2017, 2-4 versus 10-19 years old (aIRR = 15.36; 95% CI: 12.09-19.52), and for males versus females (aIRR = 1.34; 95% CI 1.16-1.55). Black children (non-Hispanic and Hispanic) had higher rates than non-Hispanic White children (aIRR = 2.51; 95% CI 2.10-2.99; and aIRR = 2.04; 95% CI: 1.22-3.39, respectively). Children born in the Midwest, Northeast and South had higher rates than those born in the West (P < .01 for each comparison). Children with a parental history of asthma had rates nearly 3 times higher than those without such history (aIRR = 2.90; 95% CI: 2.43-3.46).

CONCLUSIONS

Factors associated with time, geography, age, race and ethnicity, sex, and parental history appear to influence the inception of ARE among children and adolescents.

Genome-wide admixture and association analysis identifies African ancestry-specific risk loci of eosinophilic esophagitis in African Americans

BACKGROUND

Eosinophilic esophagitis (EoE), a chronic allergic inflammatory disease, is linked to multiple genetic risk factors, but studies have focused on populations of European ancestry. Few studies have assessed Black or African American (AA) populations for loci involved in EoE susceptibility.

OBJECTIVE

We performed admixture mapping (AM) and genome-wide association study (GWAS) of EoE using participants from AA populations.

METHODS

We conducted AM and GWAS of EoE using 137 EoE cases and 1465 healthy controls from the AA population. Samples were genotyped using molecular evolutionary genetics analysis (MEGA). Genotype imputation was carried out with the Consortium on Asthma Among African-Ancestry Populations in the Americas (CAAPA) reference panel using the Michigan Imputation Server. Global and local ancestry inference was carried out, followed by fine mapping and RNA sequencing. After quality control filtering, over 6,000,000 variants were tested by logistic regression adjusted for sex, age, and global ancestry.

RESULTS

The global African ancestry proportion was found to be significantly lower among cases than controls (0.751 vs 0.786, P = .012). Case-only AM identified 3 significant loci (9p13.3, 12q24.22-23, and 15q11.2) associated with EoE, of which 12q24.22-23 and 9p13.3 were further replicated in the case-control analysis, with associations observed with African ancestry. Fine mapping and multiomic functional annotations prioritized the variants rs11068264 (FBXW8) and rs7307331 (VSIG10) at 12q24.23 and rs2297879 (ARHGEF39) at 9p13.3. GWAS identified 1 genome-wide significant locus at chromosome 1p22.3 (rs17131726, DDAH1) and 10 other suggestive loci. Most GWAS variants were low-frequency African ancestry-specific variants. RNA sequencing revealed that esophageal DDAH1 and VSIG10 were downregulated and ARHGEF39 upregulated among EoE cases.

CONCLUSIONS

GWAS and AM for EoE in AA revealed that African ancestry-specific genetic susceptibility loci exist at 1p22.3, 9p13.3, and 12q24.23, providing evidence of ancestry-specific inheritance of EoE. More independent genetic studies of different ancestries for EoE are needed.

New considerations of health disparities within allergy and immunology

The pandemic, political upheavals, and social justice efforts in our society have resulted in attention to persistent health disparities and the urgent need to address them. Using a scoping review, we describe published updates to address disparities and targets for interventions to improve gaps in care within allergy and immunology. These disparities-related studies provide a broad view of our current understanding of how social determinants of health threaten patient outcomes and our ability to advance health equity efforts in our field. We outline next steps to improve access to care and advance health equity for patients with allergic/immunologic diseases through actions taken at the individual, community, and policy levels, which could be applied outside of our field. Key among these are efforts to increase the diversity among our trainees, providers, and scientific teams and enhancing efforts to participate in advocacy work and public health interventions. Addressing health disparities requires advancing our understanding of the interplay between social and structural barriers to care and enacting the needed interventions in various key areas to effect change.

Towards the multileveled and processual conceptualisation of racialised individuals in biomedical research

In this paper, we discuss the processes of racialisation on the example of biomedical research. We argue that applying the concept of racialisation in biomedical research can be much more precise, informative and suitable than currently used categories, such as race and ethnicity. For this purpose, we construct a model of the different processes affecting and co-shaping the racialisation of an individual, and consider these in relation to biomedical research, particularly to studies on hypertension. We finish with a discussion on the potential application of our proposition to institutional guidelines on the use of racial categories in biomedical research.

Socioeconomic status associates with worse asthma morbidity among Black and Latinx adults

BACKGROUND

Asthma disproportionately affects African American/Black (AA/B) and Hispanic/Latinx (H/L) patients and individuals with low socioeconomic status (SES), but the relationship between SES and asthma morbidity within these racial/ethnic groups is inadequately understood.

OBJECTIVE

To determine the relationship between SES and asthma morbidity among AA/B and H/L adults with moderate to severe asthma using multidomain SES frameworks and mediation analyses.

METHODS

We analyzed enrollment data from the PeRson EmPowered Asthma RElief randomized trial, evaluating inhaled corticosteroid supplementation to rescue therapy. We tested for direct and indirect relationships between SES and asthma morbidity using structural equation models. For SES, we used a latent variable defined by poverty, education, and unemployment. For asthma morbidity, we used self-reported asthma exacerbations in the year before enrollment (corticosteroid bursts, emergency room/urgent care visits, or hospitalizations), and Asthma Control Test scores. We tested for mediation via health literacy, perceived stress, and self-reported discrimination. All models adjusted for age, sex, body mass index, ethnicity, and comorbidities.

RESULTS

Among 990 AA/B and H/L adults, low SES (latent variable) was directly associated with hospitalizations (β = 0.24) and worse Asthma Control Test scores (β = 0.20). Stress partially mediated the relationship between SES and increased emergency room/urgent care visits and worse asthma control (β = 0.03 and = 0.05, respectively). Individual SES domains were directly associated with asthma morbidity. Stress mediated indirect associations between low educational attainment and unemployment with worse asthma control (β = 0.05 and = 0.06, respectively).

CONCLUSIONS

Lower SES is directly, and indirectly through stress, associated with asthma morbidity among AA/B and H/L adults. Identification of stressors and relevant management strategies may lessen asthma-related morbidity among these populations.

Allergen immunotherapy and shared decision-making

Clinical decision-making in allergic rhinoconjunctivitis management involves a significant degree of complexity given the number of pharmaceutical agents; the option for allergen immunotherapy (AIT); and the risk for disease advancement, including the development of asthma as well as new environmental allergic sensitivities. Given the complex array of treatment options that are currently available, there is an opportunity to use a shared decision-making (SDM) approach with associated aids and tools that facilitate the interactive participation of practitioners and patients in the SDM process. This article reviews the general constructs of SDM, the unmet need for SDM aids, the collection of patient preference data for allergic rhinoconjunctivitis, the utility of SDM aids which have been specifically created for AIT, and outlines actionable steps to implement AIT SDM in clinical practice.

The Role of Physician Advocacy in Achieving Health Equity: Where Is the Allergist-Immunologist?

As allergists and immunologists many of us have likely worked in the capacity of being an advocate for individual patients. However, how many of us are aware of our ability to be effective advocates who address root causes of health issues through policy changes? Physician advocacy is not a core competency medical specialty training (except pediatrics), yet physicians' clinical and research expertise and professional experience can be leveraged to shape policy. This rostrum describes the spectrum of activities for a physician advocate, barriers to physician advocacy, and actionable steps to encouraging the training and expansion of advocacy efforts by allergists and immunologists.

Pediatric asthma incidence rates in the United States from 1980 to 2017

BACKGROUND

Few studies have examined longitudinal asthma incidence rates (IRs) from a public health surveillance perspective.

OBJECTIVE

Our aim was to calculate descriptive asthma IRs in children over time with consideration for demographics and parental asthma history.

METHODS

Data from 9 US birth cohorts were pooled into 1 population covering the period from 1980 to 2017. The outcome was earliest parental report of a doctor diagnosis of asthma. IRs per 1,000 person-years were calculated.

RESULTS

The racial/ethnic backgrounds of the 6,283 children studied were as follows: 55% European American (EA), 25.5% African American (AA), 9.5% Mexican-Hispanic American (MA) and 8.5% Caribbean-Hispanic American (CA). The average follow-up was 10.4 years (SD = 8.5 years; median = 8.4 years), totaling 65,291 person-years, with 1789 asthma diagnoses yielding a crude IR of 27.5 per 1,000 person-years (95% CI = 26.3-28.8). Age-specific rates were highest among children aged 0 to 4 years, notably from 1995 to 1999, with a decline in EA and MA children in 2000 to 2004 followed by a decline in AA and CA children in 2010 to 2014. Parental asthma history was associated with statistically significantly increased rates. IRs were similar and higher in AA and CA children versus lower but similar in EA and MA children. The differential rates by sex from birth through adolescence principally resulted from a decline in rates among males but relatively stable rates among females.

CONCLUSIONS

US childhood asthma IRs varied dramatically by age, sex, parental asthma history, race/ethnicity, and calendar year. Higher rates in the 0- to 4-year-olds group, particularly among AA/CA males with a parental history of asthma, as well as changes in rates over time and by demographic factors, suggest that asthma is driven by complex interactions between genetic susceptibility and variation in time-dependent environmental and social factors.

Reframing racial and ethnic disparities in atopic dermatitis in Black and Latinx populations

Black people in the United States experience greater atopic dermatitis (AD) prevalence, severity, and persistence when compared with White people. Although very little published literature describes AD in the Latinx population, additional differences in severity, persistence, and age of onset exist in contrast to White people. Thus far, genetic polymorphisms associated with increased risk and/or severity of AD are less common among Black people, so should confer reduced, rather than the observed increased, AD risk among Black people. Little is known regarding genetic risk factors in Latinx people. In contrast, there is consistent evidence that socioeconomic, environmental, and health care factors influence AD prevalence, severity, and/or persistence, and these same risk factors are more common among racial and ethnic minority populations as a result of racism. Researchers too often pursue genetic explanations for racial and ethnic AD disparities when the evidence points to the importance of contextual, rather than genetic, causes of these disparities. Reframing the prevailing view that innate differences among racial and ethnic groups are responsible for these disparities by emphasizing the role of racism and its downstream effects on contextual factors will be a critical first step toward shrinking these disparities.

Adverse Childhood Experiences and Association With Pediatric Asthma Severity in the 2016-2017 National Survey of Children's Health

OBJECTIVES

Prior studies have found that adverse childhood experiences (ACEs) are associated with asthma prevalence and onset, presumably related to stress and increased inflammation. We hypothesized that ACEs may be associated with asthma severity as well. We studied the 2016-2017 US National Survey of Children's Health dataset to explore the relationship between ACEs and pediatric asthma severity.

METHODS

We analyzed children ages 0 to 17 years old who had current caregiver-reported asthma diagnosed by a healthcare provider. We reported descriptive characteristics using chi-square analysis of variance (ANOVA) and used multivariable regression analysis to assess the relationship of cumulative and individual ACEs with asthma severity. Survey sampling weights and SAS survey procedures were implemented to produce nationally representative results.

RESULTS

Our analysis included 3691 children, representing a population of 5,465,926. Unadjusted analysis demonstrated that ACEs - particularly household economic hardship, parent/guardian served time in jail, witnessed household violence, or victim/witness of neighborhood violence - were each associated with higher odds of moderate/severe caregiver-reported asthma. After controlling for confounders possibly associated with both exposure (ACEs) and outcome (asthma severity), children who witnessed parent/adult violence had higher adjusted odds of caregiver-reported moderate/severe asthma. (1.67, confidence interval 1.05-2.64, P = .03) CONCLUSIONS: Intrafamilial witnessed household violence is significantly associated with caregiver-reported moderate/severe asthma.

Exacerbation-Prone Asthma: A Biological Phenotype or a Social Construct

Asthma is a complex syndrome with multiple phenotypes and endotypes. Asthma exacerbations are not only the clearest indictor of the morbidity of asthma and of the risk for mortality due to asthma, but also comprise a significant amount of the cost to care for poorly controlled asthma. There continues to be significant disparity in the prevalence, mortality, and morbidity due to asthma. Patients with asthma who suffer recurrent exacerbations are considered to have exacerbation-prone asthma (EPA). Efforts to characterize patients with frequent exacerbations show that the etiology is likely multifactorial. Research to determine the intrinsic risk factors for EPA include studies of both genetic and inflammatory biomarkers. External factors contributing to exacerbations have been extensively reviewed and include viral infection, environmental exposures, air pollution, and psychosocial and economic barriers to optimizing health. It is likely that EPA occurs when patients who have an increased underlying intrinsic/biological risk are placed in a given exposome (environments with a variety of exposures and triggers including allergens, pollution, stress, barriers, and occupational exposures). It is the social construct combined with underlying biology that frequently drives an EPA phenotype.

Hereditary angioedema and shared decision making

Clinical decision-making in hereditary angioedema (HAE) management involves a high degree of complexity given the number of therapeutic agents that are available and the risk for significant morbidity and potential mortality attributable to the disease. Given this complexity, there is an opportunity to develop shared decision-making (SDM) aids and/or tools that would facilitate the interactive participation of practitioners and patients in the SDM process. This article reviews the general constructs of SDM, the unmet need for SDM in HAE, and the steps necessary to create a SDM tool specific for HAE, and outlines the challenges that must be navigated to guide the establishment and widespread implementation of SDM in the management of HAE.

mSphere of Influence: Frameshift-a Vision for Human Microbiome Research

Ariangela J. Kozik studies the respiratory microbiome as it relates to asthma. In this mSphere of Influence article, she reflects on how two papers, “Time’s up to adopt a biopsychosocial model to address racial and ethnic disparities in asthma outcomes” (E. C. Matsui, A. S. Adamson, and R. D. Peng, Allergy Clin Immunol 143:2024–2025, 2019, https://doi.org/10.1016/j.jaci.2019.03.015) and “Health disparities and the microbiome” (K.

Ariangela J. Kozik studies the respiratory microbiome as it relates to asthma. In this mSphere of Influence article, she reflects on how two papers, “Time’s up to adopt a biopsychosocial model to address racial and ethnic disparities in asthma outcomes” (E. C. Matsui, A. S. Adamson, and R. D. Peng, Allergy Clin Immunol 143:2024–2025, 2019, https://doi.org/10.1016/j.jaci.2019.03.015) and “Health disparities and the microbiome” (K. Findley, D. R. Williams, E. A. Grice, and V. L. Bonham, Trends Microbiol 24:847–850, 2016, https://doi.org/10.1016/j.tim.2016.08.001), shape her approach to human microbiome research.

Sociocultural Influences on Disparities in United States Children with Atopic Dermatitis: A Narrative Review of the Literature

Approximately 13% of United States (US) children have atopic dermatitis (AD), also known as eczema. AD is a chronic skin condition associated with significant burdens on quality of life and both individual and overall health-care system costs. The pathogenesis of AD is considered to be multifactorial, with biologic factors such as family history and genetics often reported as influencing risk. Some lesser discussed determinants of AD prevalence and severity are sociocultural, such as race/ethnicity, neighborhood, housing type, income level, and family structure. While several factors appear to contribute to disparities in childhood AD, black or African American race/ethnicity most significantly predicts AD prevalence, severity, disease control, access to care, and family impact. There is a shortage of research related to disparities in AD, an important topic considering the large percentage of families that are affected by the disease. This article is a narrative literature review of sociocultural influences on AD disparities in US children. The purpose of this review is to increase awareness of these important risk factors and to suggest related, future areas of research that may positively impact overall outcomes in children with AD. Much work remains to be done in order to ensure equitable care and outcomes among all children with AD.

The Impact of Social Determinants of Health on Children with Asthma

SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.

Achieving the Quadruple Aim to deliver value-based allergy care in an ever-evolving health care system

OBJECTIVE

To define the concept of value-based care in allergy, and to review challenges and opportunities in value-based health care delivery for allergists and immunologists.

DATA SOURCES

Articles describing practice variation, health care financing and reimbursement, shared decision-making, cost-effective health care delivery, patient-reported outcome measures, social determinants of health, and screening.

STUDY SELECTIONS

A narrative review detailing concepts and approaches to improve value-based health care in the context of the Quadruple Aim to address the patient and physician experience, cost, and population health.

RESULTS

Efforts to improve cost-effective care can be informed by understanding unwarranted geographic practice variation and benchmarking best practices. Although evidence suggests that shared decision-making and addressing social determinants of health have critical roles in high-quality care, some practices such as routine laboratory screening for urticaria, premedication to prevent recurrent low- or iso-osmolar contrast reactions, extended observation of resolved anaphylaxis, food allergy screening, and penicillin allergy overdiagnosis have high costs in relation to overall societal benefit. Food allergy prevention, newborn screening for severe combined immune deficiency, and penicillin delabeling are examples of population-based opportunities in which allergists and immunologists can assist in creating health care value. Although efforts to incentivize value-based care have emerged in recent years, the degree to which process measures improve patient-important outcomes remain uncertain. Clinician wellness must be made a priority for continued effective practice.

CONCLUSION

As health care systems continue to evolve, allergists and immunologists will play a key role in optimizing value by translating emerging evidence into practice and communicating novel approaches to prevent and treat allergic diseases.

Asthma epidemiology and risk factors

Asthma is a clinical syndrome that affects all age groups. Asthma prevalence worldwide has seen a rapid increase in the latter part of the last century. Recent data has shown that asthma prevalence has plateaued and even decreased in some areas of the world, despite continuing to increase in other areas of the world. Many risk factors have been associated with asthma and the differences in distributions of these risk factors may explain the differences in prevalence. This article will review recent trends in the prevalence of asthma and recent studies that investigate risk factors of asthma.

Ecological interactions in asthma: from environment to microbiota and immune responses

PURPOSE OF REVIEW

Asthma is a heterogeneous condition shaped not only by genetics but also host conditioning by environmental factors. Recognizing the ecological context of microbe-immune interactions across environments and body sites is a necessary step toward better understanding how human microbiota influence or drive the pathogenesis and pathophysiology of asthma in its various presentations.

RECENT FINDINGS

There is increasing evidence of a critical role for microbiota in asthma pathogenesis and outcomes across various body compartments, including the upper and lower airways, and gut. We discuss recent studies from this area including: development of a method to quantify microbial farm-effect in nonfarm environments, relationships between environmental microbial exposures and asthma prevalence across different geographies, microbiome-mediated responses to ozone, and microbiome-immune interactions within and across body compartments. Beyond bacteria, recent reports of asthma-associated differences in archaea and fungal organisms also are highlighted.

SUMMARY

Collective evidence warrants application of an ecological framework to advance mechanistic insights into microbiota-immune interactions in asthma. This is necessary to achieve goals of developing successful therapeutic interventions targeting modification of microbiomes.

Applying a biopsychosocial model to inner city asthma: Recent approaches to address pediatric asthma health disparities

Pediatric asthma in inner cities is often severe and children living in these urban locations with socioeconomic disadvantage experience greater asthma morbidity. There are many interconnected risk factors that individually, and in combination, enhance asthma morbidity. These include biologic factors innate to the child, such as genetics and allergen susceptibility, as well as factors related to the family and neighborhood context. The biopsychosocial model can be used to frame these risk factors and develop interventions specific to the inner city. Successful inner city asthma interventions exist and key characteristics include multi-tiered components that operate within the community to coordinate disease management resources between patients, families and health care systems.