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Asthma effects among African American children: an increase in asthma coincides with significant reduction of outdoor air pollution-Elizabeth Siteman

Introduction:
Over the past twenty years, the prevalence of asthma among children has increased drastically. According to the National Center for Health Statistics and the Centers for Disease Control and Prevention, there were 6.8 million total asthma cases in the United States in 1980 and 17.3 million in 1999—children account for a vast majority of the increase in the number of these cases. The asthma rate among African American children is, on average, twice that among white children and three times that among Hispanic children (Public Health Policy Advisory Board, 2002). Asthma rates have climbed in the face of environmental pollution regulations and reductions, but the current public health approach remains focused on decreasing motor vehicle and industrial emissions in order to curb the effects of this chronic disease. This approach has not been as successful as it could be because it lacks context—it fails to pause and explore the possibilities as to why African American children are so disproportionately affected by asthma. Until public health practitioners and policy-makers examine asthma and those whom it affects from a broader perspective, the rate of the disease will continue to increase and a resolution will seem even more unattainable.

Effectiveness of Emission Policies in Reducing Asthma Rates:
The Clean Air Act Amendments of 1990 sought to achieve stricter emissions standards in order to reduce the prevalence of ozone, carbon monoxide, and particulate matter. These three air pollutants have been shown to be associated with the exacerbation of asthma symptoms, specifically among children (Wong, 2004). Such amendments to the original act did, in fact, help to improve outdoor air quality. For example, in California, ozone levels were cut in half from 1980 to 1996 (California Air Resources Board, 2006). These policies, a prime example of a power-coercive public health intervention, were successful in pollution abatement but failed to reach the overall goal of reducing asthma or reducing the severity of asthma cases (Chin and Benne, 1976). The prevalence of asthma cases did not follow the same trend, but rather increased in spite of relatively cleaner air. In order to reduce the prevalence of asthma in the U.S., public health practitioners must be willing to diagnose and contextualize the underlying risk factors contributing to the disease instead of just treating the symptoms that manifest.

The Influence of Socio-cultural Factors on Asthma Rates—Residential Segregation:
By analyzing the issue of the disproportionate effects of asthma among African Americans, specifically among African American children, a wide range of factors come to light. Some argue that genetics play a part in whether a child develops asthma or other respiratory ailments. Asthma does seem to run in families, but whether a family has a genetic predisposition to the disease or is exposed to the same risk factors is unclear. For example, the timing of the increase in asthma rates coincides with the effects of the energy crisis of the 1970s. The crisis led to the implementation of regulations designed to reduce ventilation in order to make buildings more energy efficient, ultimately increasing levels of indoor air contaminants. Those living in densely populated, urban areas were most likely to be affected by such regulations, and in turn be exposed to higher levels of indoor air contaminants. Such contaminants can make an individual more susceptible to or exacerbate an asthma attack or respiratory ailment. A large proportion of lower income families and/or minorities live in densely populated urban areas, which may offer one theory as to why African American children are at such a higher risk of being affected by asthma.

The Influence of Socio-cultural Factors on Asthma Rates—Income:
However, in a study performed at Rutgers University that analyzed the prevalence of asthma among differing income levels between Black and non-Black children (including Hispanic children), asthma rates did not significantly decline as family income increased. Rather, the study found that asthma rates were “relatively level and high across income groups…” (Miller, 2000). Such findings suggest the context in which asthma surfaces in an African American child must be analyzed further.
Another study designed to assess the effects of an intervention program, the Neighborhood Asthma Coalition, in Missouri noted that “African American patients are 3 times more likely to be hospitalized and 4 times more likely to die as a result of asthma than are white patients” (Fisher et al, 2004). African Americans are overall less likely to seek out primary care, and as these statistics show, have higher rates of hospitalization and emergency visits as a result of a lack of continuity of care. A public health approach should strive to unearth the factors that impede African Americans from visiting a doctor regularly. Whether the cause is lack of access, lack of insurance, lack of knowledge, or an inherent mistrust in the medical community, the interventions that seek to address the issue of inconsistent care must target these underlying issues in order to be successful.

The Influence of Socio-cultural Factors on Asthma Rates—Community Support:
The same study, mentioned above, in Missouri found that a number of factors prevent children from properly managing their asthma, some of which include “…poverty, exposure to environmental triggers, stresses of living in an urban areas, lack of family and community support, lack of knowledge regarding asthma and community support, and lack of knowledge regarding asthma and its treatment” (Fisher et al, 2004). The emphasis this study placed on the role of community support in determining health outcomes is very important to any public health intervention. Social science theory purports that the African American community, specifically, values the support of its members very highly. “According to researchers, traditional African American families have tended to place emphasis on the family and the broader kinship network. Kinship networks are believed to serve as a source of strength, trust, and survival” (Owens, 2002). Without this source of community empowerment to spark self-efficacy, some members of the African American community may not willingly seek out care. Lack of consistent care is detrimental to chronic disease management, such as the management of asthma.

Increased Exposure to Asthma Triggers within the Daycare/School Setting:
Another theory behind the disproportionate effects of asthma among African American children revolves around the increase in the use of daycare services. Children are in close contact with others throughout the day and are subject to certain exposures and respiratory ailments. While this theory is gaining support, there is not much evidence that African American families use daycare services markedly more so than their counterparts. However, if the daycare theory proves to have staying power, it may translate into the school setting. Overcrowded public schools in densely populated urban areas may provide similar exposures or triggers as the daycare setting. A study performed at the Arkansas Children’s Hospital looked at the characteristics of asthmatic children in Head Start programs. The study found that most children in the programs “had poor asthma control” and “only 32% of children with persistent asthma had both rescue and controller medications” (Vargas et al, 2004). The study did not evaluate the effect of the Head Start program on the severity of asthma among enrolled children.

An Alternative Approach:
Asthma has been shown to be associated with the presence of environmental triggers, such as outdoor air pollutants, indoor air contaminants, and secondhand smoke, but public health initiatives that simply target these environmental triggers fall short of the overall goal to reduce asthma rates. A more comprehensive approach must synthesize the social, cultural, biological, and environmental factors that contribute to this chronic condition. In examining the elevated prevalence of asthma among African American children, a successful public health intervention cannot just focus on controlling air pollution in the communities within which these children live. Past regulations have focused on doing so and have not made it easier for these children to breathe. Instead, an intervention that seeks to reach African American communities through asthma education, training, and management, targeting families and friends so that they know what to do when a child is having an asthma attack may enjoy more success. Using the social and behavioral science theory of self-efficacy will lead to community empowerment and ultimately lessen the stigma surrounding asthma.

References

“1990 Amendments to the Clean Air Act.” U.S. Environmental Protection Agency, 2006.

“Asthma: Epidemic Increase—Cause Unknown.” Public Health Policy Advisory Board.
March 2002. http://www.phpab.org/asthma%20report/asthma.pdf

Chin R, Benne KD. General strategies for effective change in human systems. In Bennis W et al. (eds.): The Planning of Change (3rd Edition), pp. 22-45. New York: Holt, Rinehart and Winston, 1976.

Claudio, L., Stingone, J., and J. Godbold. “Prevalence of Childhood Asthma in Urban
Communities: The Impact of Ethnicity and Income.” Annals of Epidemiology.
2006; 16(5), 332-340.

“Cleaning up the air.” California Air Resources Board, 2006.

Cohen, R., Celedon, J., Hinckson, V., et al. “Health-Care Use Among Puerto Rican and
African American Children With Asthma.” CHEST: The Cardiopulmonary and Critical Care Journal. 2005; 130; 463-471.
http://www.chestjournal.org/cgi/content/full/130/2/463

“Cross Cutting Issues: Asthma Disparities.” Washington State Asthma Plan, 2005.

Fisher, E., Strunk, R. Sussman, L., et al. “Community Organization to Reduce the Need for Acute Care for Asthma Among African American Children in Low-IncomeNeighborhoods: The Neighborhood Asthma Coalition.” Pediatrics. 2004; 114;116-123.
http://www.pediatrics.org/cgi/content/full/114/1/116

Grant, E., Lyttle, C., and K. Weiss. “Relation of Socioeconomic Factors and
Racial/Ethnic Differences in US Asthma Mortality.” American Journal of Public
Health. December 2000; 90(12), 1923-1925.

Guo, J., Jang, R., Keller, K., et al. “Impact of school-based health centers on children with asthma.” Journal of Adolescent Health. 2005; 37(4), 266-274.

Joseph, C., Ownby,D., Peterson, E., and C. Johnson. “Racial Differences in Physiologic Parameters Related to Asthma Among Middle-class Children.” CHEST: The
Cardiopulmonary and Critical Care Journal. 2000; 117; 1336-1344.
http://www.chestjournal.org/cgi/content/full/117/5/1336

Leiberman, Ben. “The Mysterious Asthma Increase.” American Council on Science and
Health. April 9, 2002. http://www.acsh.org/healthissues/newsID.113/healthissue_detail.asp

McDaniel, M., Paxson, C., and J. Waldfogel. “Racial Disparities in Childhood Asthma in the United States: Evidence From the National Health Interview Survey, 1997 to
2003.” Pediatrics. 2006; 117; 868-877.
http://www.pediatrics.org/cgi/content/full/117/5/e868

Miller, Jane E. PhD. “The Effects of Race/Ethnicity and Income on Early Childhood
Asthma Prevalence and Health Care Use.” American Journal of Public Health.
March 2000; 90(3), 428-430.

Nicholas, S., Jean-Louis, B., Ortiz, B., et al. “Addressing the Childhood Asthma Crisis in Harlem: The Harlem Children’s Zone Asthma Initiative.” American Journal of
Public Health. February 2005; 95(2), 245-249.

Nystad, W. “Daycare attendance, asthma and atopy.” Annals of Medicine. September
2000; 32(6), 390-396.

Owens, Karen B. Child & Adolescent Development: An Integrated Approach. 2002.

Sin, M., Kang, D., and M. Weaver. “Relationships of asthma knowledge, self-
management, and social support in African American adolescents with asthma.”
International Journal of Nursing Studies. 2005; 42(3), 307-313.

Slack-Smith, L., Read, A., and F. Stanley. “Experience of respiratory and allergic illness
in children attending childcare. Child: Care, Health & Development. 2002; 28(2)171.

Quinn, K., Shalowitz, M., Berry, C., et al. “Racial and Ethnic Disparities in Diagnosed and Possible Undiagnosed Asthma Among Public-School Children in Chicago.” American Journal of Public Health. September 2006; 96(9), 1599-1603.

Tanne, Janice. “Asthma ‘crisis’ for black Americans.” BMJ. August 11, 2001.

Vargas, P., Simpson, P., Wheeler, J., et al. “Characteristics of children with asthma who are enrolled in a Head Start program.” Journal of Allergy and Clinical
Immunology. 2004; 114(3), 499-504.

Wong, E., Gohlke, J., Griffith, W., et al. “Assessing the Health Benefits of Air Pollution Reduction for Children.” Environmental Health Perspectives. 112(2): 2004.

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