Level of education and asthma control in adult-onset asthma

Understanding the determinants of self-reported asthma in Turkey: insights from national data on individual, lifestyle, socioeconomic, and healthcare access factors

Asthma, influenced by genetic, environmental, and social factors is leading to poor outcomes and preventable mortality due to inadequate care and limited access to effective treatments. This study aimed to analyze self-reported asthma prevalence in Turkey, focusing on its determinants, such as individual factors, lifestyle, socioeconomic status, and healthcare access.This study conducts a secondary analysis of the 2019 Turkiye Health Survey (THS), employing a nationally representative cross-sectional design by the Turkish Statistical Institute. The sampling utilized a stratified, two-stage cluster sampling method, with data from 16,976 adults (aged 15 years and older) analyzed for asthma determinants. The independent variables are categorized into four domains: individual factors, lifestyle assessment, socioeconomic factors, and access to the healthcare services.The prevalence of asthma is 9.8%, varying significantly across demographics. Higher asthma rates are observed among older, divorced/widowed individuals, those with communication difficulties, and obese individuals. Cost-related unmet healthcare needs and appointment scheduling delays increase asthma risk. Logistic regression models identified age, marital status, obesity, education level, and healthcare access as significant predictors of asthma.This study underscores the multifaceted determinants of asthma in Turkey, highlighting the necessity for targeted interventions addressing individual, lifestyle, socioeconomic, and healthcare access factors.

Effects of Family-Supported Healthcare on Children with Asthma

Introduction

Healthcare is essential for asthma control, however, whether family-supported healthcare improves therapeutic effects in childhood asthma remains unclear.

Methods

The enrolled patients were randomly divided into control and intervention groups. The pulmonary function was evaluated by forced expiratory volume in 1 s as a percentage of forced vital capacity (FEV1/FVC) and fractional exhaled nitric oxide (FeNO). Asthma control and life quality were assessed via a childhood asthma control test and pediatric asthma quality of life questionnaire. Inflammatory cytokines interleukin-6 (IL-6) and interleukin-17 (IL-17) were determined by enzyme-linked immunosorbent assay.

Results

No significant differences existed in the basic characteristics of asthma children and their parents among two groups. The increase of FEV1/FVC was higher in the intervention group versus the control group (76.47 ± 10.76% vs 69.76 ± 8.88%, p = 0.001 at the time of post-intervention), and the decrease of FeNO was greater in the intervention group (30.43 ± 6.85 bbp vs 35.64 ± 6.62 bbp, p = 0.003 at the time of post-intervention). Family-supported healthcare highly improved asthma control and quality of life in childhood asthma post-treatment. Meanwhile, the inflammatory cytokines IL-17 (118.14 ± 25.79 pg/mL in intervention group vs 142.86 ± 28.68 pg/mL in control group, p = 0.004 at the time of post-intervention) and IL-6 (103.76 ± 23.11 pg/mL in intervention group vs 119.73 ± 22.68 pg/mL in control group, p = 0.009 at the time of post-intervention) significantly decreased by family-supported healthcare intervention. Importantly, acute exacerbation (80.8% in intervention group vs 95.7% in control group, p = 0.030) and rehospitalization cases (88.5% in intervention group vs 100% in control group, p = 0.028) also decreased by family-supported healthcare intervention.

Discussion

Family-supported healthcare improves pulmonary function and quality of life while alleviates inflammation, acute exacerbation, and rehospitalization in childhood asthma post-routine treatment.

Treatable traits and exacerbation risk in patients with uncontrolled asthma prescribed GINA step 1-3 treatment: A nationwide asthma cohort study

BACKGROUND AND OBJECTIVE

Uncontrolled asthma in patients treated for mild/moderate disease could be caused by non-pulmonary treatable traits (TTs) that affect asthma control negatively. We aimed to identify demographic characteristics, behavioural (smoking) and extrapulmonary (obesity, comorbidities) TTs and the risk for future exacerbations among patients with uncontrolled asthma prescribed step 1-3 treatment according to the Global Initiative for Asthma (GINA).

METHODS

Twenty-eight thousand five hundred eighty-four asthma patients (≥18 y) with a registration in the Swedish National Airway Register between 2017 and 2019 were included (index-date). The database was linked to other national registers to obtain information on prescribed drugs 2-years pre-index and exacerbations 1-year post-index. Asthma treatment was classified into step 1-3 or 4-5, and uncontrolled asthma was defined based on symptom control, exacerbations and lung function.

RESULTS

GINA step 1-3 included 17,318 patients, of which 9586 (55%) were uncontrolled (UCA 1-3). In adjusted analyses, UCA 1-3 was associated with female sex (OR 1.34, 95% CI 1.27-1.41), older age (1.00, 1.00-1.00), primary education (1.30, 1.20-1.40) and secondary education (1.19, 1.12-1.26), and TTs such as smoking (1.25, 1.15-1.36), obesity (1.23, 1.15-1.32), cardiovascular disease (1.12, 1.06-1.20) and depression/anxiety (1.13, 1.06-1.21). Furthermore, UCA 1-3 was associated with future exacerbations; oral corticosteroids (1.90, 1.74-2.09) and asthma hospitalization (2.55, 2.17-3.00), respectively, also when adjusted for treatment step 4-5.

CONCLUSION

Over 50% of patients treated for mild/moderate asthma had an uncontrolled disease. Assessing and managing of TTs such as smoking, obesity and comorbidities should be conducted in a holistic manner, as these patients have an increased risk for future exacerbations.

Patient education needs in severe asthma, a pilot study

BACKGROUND

Severe asthma is characterized by frequent exacerbations, altered lung function, and impaired quality of life. Tailored patient education allows for the improvement of both asthma management and quality of life. Our study aimed to assess the needs of severe asthma patient in therapeutic education, according to previous therapeutic patient education background and asthma phenotype.

METHODS

Consecutive patients monitored for severe asthma in a tertiary referral center were considered for inclusion and answered a questionnaire detailing their patient education needs and the topics they would like to discuss. Asthma history, clinical and biological data, and lung function results were recorded.

RESULTS

Fifty-three patients were included and 47 (88.7%) expressed at least one need. The most frequently selected topics were "life with asthma" (83%), "treatment use" (68%), and "exacerbation management" (60%), independent of previous participation in a patient education program dedicated to asthma. Patients of older age at inclusion, uncontrolled asthma, and T2-high phenotypes were associated with different profiles of patient education needs.

CONCLUSION

Our study identified frequent and various patient educational needs among severe asthmatics, highlighting the importance of an in-depth assessment of severe asthmatics expectations and the crucial need for the development of dedicated educational tools.

Documentation of comorbidities, lifestyle factors, and asthma management during primary care scheduled asthma contacts

Systematically assessing asthma during follow-up contacts is important to accomplish comprehensive treatment. No previous long-term studies exist on how comorbidities, lifestyle factors, and asthma management details are documented in scheduled asthma contacts in primary health care (PHC). We showed comorbidities and lifestyle factors were poorly documented in PHC in this real-life, 12-year, follow-up study. Documented information on rhinitis was found in 8.9% and BMI, overweight, or obesity in ≤1.5% of the 542 scheduled asthma contacts. Of the 145 patients with scheduled asthma contacts, 6.9% had undergone revision of their inhalation technique; 16.6% had documentation of their asthma action plan. Screening of respiratory symptoms was recorded in 79% but nasal symptoms in only 15.5% of contacts. Lifestyle guidance interventions were found in <1% of contacts. These results, based on documented patient data, indicate a need exists to further improve the assessment and guidance of asthma patients in PHC.

Impact of socioeconomic factors on allergic diseases

Allergic and immunologic conditions, including asthma, food allergy, atopic dermatitis, and allergic rhinitis, are among the most common chronic conditions in children and adolescents that often last into adulthood. Although rare, inborn errors of immunity are life-altering and potentially fatal if unrecognized or untreated. Thus, allergic and immunologic conditions are both medical and public health issues that are profoundly affected by socioeconomic factors. Recently, studies have highlighted societal issues to evaluate factors at multiple levels that contribute to health inequities and the potential steps toward closing those gaps. Socioeconomic disparities can influence all aspects of care, including health care access and quality, diagnosis, management, education, and disease prevalence and outcomes. Ongoing research, engagement, and deliberate investment of resources by relevant stakeholders and advocacy approaches are needed to identify and address the impact of socioeconomics on health care disparities and outcomes among patients with allergic and immunologic diseases.

Relationship Between Asthma Control Status and Health-Related Quality of Life in Japan: A Cross-Sectional Mixed-Methods Study

INTRODUCTION

There is limited information regarding multidimensional relationships between asthma control and health-related quality of life (HRQoL), work productivity, and asthma symptom burden in Japan. Furthermore, systematic qualitative investigations about asthma burden have not been performed.

METHODS

This cross-sectional, mixed-methods study included Japanese patients (≥ 20 years) with asthma adherent to inhaled corticosteroids/long-acting β2-agonists (ICS/LABA). The primary endpoint was impact of asthma on HRQoL, measured using the Asthma Health Questionnaire-33 (AHQ-33). Secondary endpoints were cough burden (Japanese-adapted Leicester Cough Questionnaire [J-LCQ]) and impact of asthma on work/activities (asthma-specific Work Productivity and Activity Impairment Questionnaire [WPAI:Asthma]). Quantitative data were assessed for the overall population and for well-controlled (WC) and not well-controlled (NWC) asthma subgroups. Qualitative verbal interviews further assessed the impact of NWC asthma on patients' HRQoL; emergent themes were extracted using thematic analyses.

RESULTS

Of 454 patients, 45.2% (n = 205) had NWC asthma. Patients with NWC asthma had significantly worse asthma- and cough-related HRQoL across all AHQ-33 and J-LCQ domains and significantly greater work and activity impairment versus patients with WC asthma, across all assessed WPAI:Asthma domains. AHQ-33 total score was highly correlated with J-LCQ total and domain scores (r = - 0.8132 to r = - 0.7407). Nine themes emerged from qualitative interviews and confirmed that patients with NWC asthma had considerable HRQoL impairment due to asthma symptoms.

CONCLUSIONS

Patients with NWC asthma had higher symptom burden and worse HRQoL than patients with WC asthma, despite ICS/LABA adherence. Cough burden correlated with HRQoL, suggesting cough may be one of the key markers to inform treatment strategy for patients with asthma.

Less Social Deprivation Is Associated With Better Health-Related Quality of Life in Asthma and Is Mediated by Less Anxiety and Better Sleep Quality

BACKGROUND

Previous studies on health-related quality of life (HRQoL) in asthma have mainly focused on clinical and environmental determinants. Little is known about the role of social determinants on HRQoL in asthma.

OBJECTIVES

We aimed to investigate the association between social deprivation and HRQoL in asthma.

METHODS

A total of 691 adult asthmatics from Canada, India, New Zealand, and the United Kingdom were administered a digital questionnaire containing demographic information and questions about social and psychological attributes, sleep disturbances, and alcohol abuse. HRQoL was measured using the Short Form of the Chronic Respiratory Questionnaire (SF-CRQ). We analyzed the direct and indirect relationships between social deprivation and HRQoL using structural equation models with social deprivation as a latent variable. We tested for mediation via anxiety, depression, sleep disturbances, and alcohol abuse.

RESULTS

We found that less social deprivation (latent variable) was directly associated with better SF-CRQ domain scores such as dyspnea (regression coefficient β: 0.33; 95% confidence interval [CI]: 0.07 to 0.58), fatigue (β: 0.39; 95% CI: 0.14 to 0.64), and emotional function (β: 0.37; 95% CI: 0.11 to 0.62), but with the worse mastery score (β: -0.29; 95% CI: -0.55 to -0.03); however, those associations varied across participating countries. We also observed that among all individual social deprivation indicators, education, companionship, emotional support, instrumental support, and social isolation were directly associated with HRQoL, and the relationship between social deprivation and HRQoL was mediated through anxiety and sleep disturbances.

CONCLUSIONS

Our results demonstrated that less social deprivation was directly, and indirectly through less anxiety and better sleep quality, associated with better HRQoL in asthma.

Multiple manifestations of uncontrolled asthma increase the risk of severe COVID-19

OBJECTIVE

Asthma control is of importance when assessing the risk of severe outcomes of COVID-19. The aim of this study was to explore associations of clinical characteristics and the effect of multiple manifestations of uncontrolled asthma with severe COVID-19.

METHODS

In 2014-2020, adult patients with uncontrolled asthma, defined as Asthma Control Test (ACT) ≤19 were identified in the Swedish National Airway Register (SNAR) (n = 24533). The SNAR database, including clinical data, was linked with national registers to identify patients with severe COVID-19 (n = 221). The effect of multiple manifestations of uncontrolled asthma was based on: 1) ACT ≤15, 2) frequent exacerbations and 3) previous asthma inpatient/secondary care and evaluated stepwise. Poisson regression analyses were conducted with severe COVID-19 as the dependent variable.

RESULTS

In this cohort with uncontrolled asthma, obesity was the strongest independent risk factor for severe COVID-19 in both sexes, but even greater in men. Multiple manifestations of uncontrolled asthma were more common among those with severe COVID-19 vs. without: one, 45.7 vs. 42.3%, two, 18.1 vs. 9.1% and three, 5.0 vs. 2.1%. The risk ratio (RR) of severe COVID-19 increased with an increasing number of manifestations of uncontrolled asthma: one, RR 1.49 (95% CI 1.09-2.02), two, RR 2.42 (95% CI 1.64-3.57) and three, RR 2.96 (95% CI 1.57-5.60), when adjusted for sex, age, and BMI.

CONCLUSIONS

It is important to consider the effect of multiple manifestations of uncontrolled asthma and obesity when assessing patients with COVID-19, as this increases the risk of severe outcomes substantially.

Structural Racism and the Social Determinants of Health in Asthma

Asthma prevalence and morbidity are disproportionately higher among minoritized communities in the United States. Racial and ethnic disparities in asthma result from complex interactions across biological, environmental, and social factors. Asthma is considered a complex heterogeneous disease consisting of different phenotypes, some of which may be more common in individuals impacted by the downstream effects of structural racism and lack of access to the social determinants of health. Structural racism across generations has created and reinforced inequitable systems through policies and practices which are embedded in the economic, educational, health care, and justice systems (Bailey et al., N Engl J Med 384(8):768-773, 2021; Bailey et al., Lancet 389:1453-1463, 2017; Williams et al., Annu Rev Public Health 40:105-125, 2019). This manifests in an inequitable distribution of resources and the social determinants of health affecting an individual's physical and social environment (Bailey et al., Lancet 389:1453-1463, 2017; Thakur et al., Am J Respir Crit Care Med 202:943-949, 2020; Martinez et al., J Allergy Clin Immunol 148(5):1112-1120, 2021). In this chapter, we outline how inequity in housing, zoning laws, urban planning, education, employment, healthcare access, and healthcare delivery is linked to higher asthma prevalence and morbidity. We also describe the role that chronic physiologic stress has on asthma by enhancing neuroimmune and immunologic responses to environmental exposures. Interventions aimed at addressing the physical or social environment of an individual or community have been shown to improve asthma outcomes in patients at higher risk of severe disease.

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.

High Use of Antidepressant Medication in Both Mild-to-Modelate and Possible Severe Asthma - A Nationwide Cohort Study

PURPOSE

In asthma, increased severity has been linked to depression assessed as assessed by patient-reported outcomes. However, little is known about predictors of antidepressant use in asthma compared to the background population.

METHODS

The study consists of 60,534 asthma patients aged 18-45 and a 1:1 age- and sex-matched control group. Using national registries and prescription data, the prevalence of and risk factors for antidepressant use were investigated by logistic regression adjusted for age, sex, workforce and civil status, income- and education-level and comorbidity. Results presented as odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

A total of 16% and 22%, respectively, among patients with mild-to-moderate and possible severe asthma redeemed antidepressant drugs, compared to 10% of controls. Antidepressant use was more prevalent amongst patients with high rescue medication use (>600 annual doses) and those with a history of moderate or severe exacerbation(s). Both mild-to-moderate and possible severe asthma were independent risk factors for antidepressant use (OR 1.40 (95% CI 1.35, 1.46) and OR 1.55 (95% CI 1.41, 1.70), respectively). Female sex, age, being divorced or never married, having only primary education or currently being under education, as well as being on welfare/transfer income increased odds of antidepressant use. Completing higher education and having high income were associated with lower odds.

CONCLUSION

In asthma, antidepressant use is significantly higher than in the background population. Even after adjusting for known risk factors, asthma remains a predictor of antidepressant use, signalling a psychologic burden related to living with asthma.

Socioeconomic biases in asthma control and specialist referral of possible severe asthma

BACKGROUND

Although socioeconomic impact on asthma control has been investigated, little is known about its relation to specialist referral of patients with possible severe asthma, especially in a public healthcare setting. The present study aims to identify socioeconomic patterns in disease control and referral of patients with asthma in a nationwide cohort of adult patients treated with inhaled corticosteroid (ICS).

METHODS

Asthma patients fulfilling the following: aged 18-45 and redeeming ≥2 prescriptions of ICS during 2014-18 based on data from Danish national registers were included. Possible severe asthma was defined as GINA 2020 Step 4 (with either ≥2 courses of systemic steroids or ≥1 hospitalisation) or Step 5 treatment. Findings presented as odds ratio (OR) (95% confidence intervals).

RESULTS

Of 60 534 patients (median age 34, 55% female), 3275 (5.7%) were deemed as having possible severe asthma, of whom 61% were managed in primary care alone.Odds of specialist management for possible severe asthma decreased with age (OR 0.66 (0.51-0.85)), 36-45 versus 18-25 years), male sex (OR 0.75 (0.64-0.87)), residence outside the Capital Region (OR 0.70 (0.59-0.82)) and with receiving unemployment or disability benefits OR 0.75 (0.59-0.95)).Having completed higher education increased odds of specialist referral (OR 1.28 (1.03-1.59)), when compared to patients with basic education.

CONCLUSION

Even in settings with nationally available free access to specialist care, the majority of patients with possible severe asthma are managed in primary care. Referral of at-risk asthma patients differs across socioeconomic parameters, calling for initiatives to identify and actively refer these patients.