Considerations in Culturally Directed Asthma Disease Management Programs
Michelle M. Cloutier
Asthma is one of the most common chronic diseases of adults and children in industrialized countries, and has had a marked increase in prevalence over the past 25 years. Asthma disproportionately affects under-represented minority populations, with African Americans and (some) Hispanics having higher rates than other groups. Racial and ethnic disparities in asthma prevalence and severity exist and are partially explained by environmental, social, cultural, and economic factors. Genetic factors also clearly affect an individual's susceptibility to asthma. Numerous strategies to reduce disparities surrounding asthma incidence, morbidity, and mortality have been proposed, and a few of them are highlighted in this article. However, as a whole, these strategies have done little to reduce ethnic disparities in asthma-related morbidity. Case detection and prescription of appropriate therapy, particularly the prescription of inhaled corticosteroids, are essential but not sufficient to improve outcomes. Family and patient-centered asthma education and culturally focussed approaches in communities who share common belief sets have been shown to reduce asthma symptom days and to improve functional health status; however, most strategies have incorporated interventions to improve therapy in addition to patient education, making it difficult to determine which component (improved therapy, patient education, or both) has resulted in the improved outcomes. Language concordance and the field testing of patient materials are important for the success of educational programs, while the setting of the education (emergency departments, hospitals, communities, or schools) does not seem as important as the intervention itself. The quality of the patient-physician interaction and the cultural and cross-cultural competence of the clinician are also important factors capable of reducing disparities in the asthma care provided to minority populations and women, while the effectiveness of environmental control strategies in reducing asthma morbidity, especially in urban-dwelling, low socioeconomic groups, has had conflicting results. While there have been reasonably few community-level interventions, these interventions have been adapted to the ethnic, social, and economic characteristics of specific populations and may hold promise in the future. At the present time, interventions that improve asthma diagnosis, increase the appropriate use of inhaled corticosteroid therapy, and assure access to medication in the context of a family-centered, community-based, culturally-appropriate intervention hold the greatest promise of reducing disparities in asthma morbidity and mortality in ethnically and socioeconomically diverse populations. In all likelihood, there is no single intervention that will reduce the especially high asthma burden in minority populations. Large-scale, cost-effective, systematic, standardized approaches that are relevant to populations and are culturally, socially, and economically diverse are needed.
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