Asthma Disparities in Latino Children:Acculturation,Illness Representations & CAM

Racial and ethnic disparities in asthma health outcomes have been increasing in the United States. These disparities are so striking that researchers and public health officials have issued a call for action to understand why this is occurring. Compared with non-minority children, minority children use controller medication less often, have less continuity of care, and visit emergency departments more frequently. Especially noteworthy has been the increasing prevalence of asthma among Latino (primarily Puerto Rican) children. Individuals of Mexican and Puerto Rican origin constitute 73% of the Latino population in the U.S. and although these two groups share similar historical origins and cultural values, significant heterogeneity exists. Researchers have tended to study Latinos as a single group but recent descriptive asthma research has confirmed differences among Latino subgroups related to prevalence, mortality and morbidity, illness beliefs, and asthma healthcare practices. Puerto Rican children exhibit the highest rates of asthma prevalence and mortality among all ethnic groups while Mexican children have the lowest rates. Asthma disproportionately affects Puerto Rican children: the adjusted odds ratio for lifetime diagnosis compared to non-Latino white children is 2.33. Genetic, environmental, healthcare system and provider factors cannot totally explain the difference in outcomes between these two groups.

Not well examined is the role that culture, acculturation, and illness representations (the way the parent interprets health and illness which influences how he/she manages the child's asthma) may play in parents' asthma treatment decisions and ultimately, children's asthma control. Parental illness representations may account for the differences in the use of complementary and alternative medicine (CAM), inhaled or oral corticosteroids, and leukotriene antagonists that have been observed between Puerto Rican and Mexican families. Acculturation may also play a role in asthma health outcomes. Less-acculturated Mexican families, even if they have known risk factors for poor health outcomes, have better outcomes than more acculturated families. Emerging evidence suggests that acculturation has opposite effects for Puerto Rican versus Mexican children with asthma. U.S. birthplace and higher acculturation among Mexican children is associated with greater risk for asthma and wheezing, while higher acculturation may be protective for Puerto Rican children in terms of diagnosis of asthma and medication adherence.

The past three decades have seen a shift in approaches to studying health and illness behavior from disease-oriented medical models to integrated bio-psycho-social models. The factors leading to asthma health disparities between Mexican and Puerto Rican children are complex and not well understood. Illness representations, the associated treatment decisions (CAM and controller medication use), and the influence of acculturation on these processes, are three factors requiring additional scrutiny. The Common Sense Model of Illness Representation is an integrated model that takes into account environmental, social, and cultural factors as well as patients' beliefs about health and illness. Because parents are the gatekeepers for their children's healthcare and ultimately make the final treatment decisions, it is parents' representation of their children's illness that influences treatment decisions and children's asthma health outcomes.

Before developing interventions that target asthma health disparities among this diverse group of Latino families, it is necessary to gain a more thorough understanding of the interaction of individual characteristics, cultural and experiential factors, social-environmental context, and healthcare system factors. The investigators also need to examine how the interaction of these factors impacts parents' illness representations, use of CAM and controller medications, and children's asthma health outcomes. This innovative study moves the research from descriptive studies of individual constructs and contexts to testing an integrated, multi-factorial model. Targeted interventions, aimed at reshaping illness representations, can be developed and implemented to integrate the family's ethnomedical belief system (medical system based on the cultural beliefs of specific ethnic groups) into the biomedical model. The proposed interdisciplinary multi-level study will address gaps in the evidence base and expand the framework for assessing disparities in asthma health outcomes among Latino children. This will be a one-year longitudinal, multi-site study among samples of Mexican and Puerto Rican parents and children aged 5-12 who have asthma. This age range was selected because children in this age group typically have not assumed daily control for managing their asthma.

The findings from this study will contribute to the knowledge base on the similarities and differences that exist between Mexican and Puerto Rican families regarding asthma illness beliefs and management strategies, and how acculturation influences these factors. Healthcare providers, regardless of their practice setting, can best treat children with asthma if they understand what beliefs parents hold about what causes asthma, the nature of asthma symptoms, its course of action (chronic versus episodic), medications and alternative therapies used in treatment, and expectations for symptom resolution. If parents' beliefs are discordant with the HCPs' beliefs and are not addressed when devising the management plan, there is increased risk for nonadherence. Healthcare providers would also do well to educate themselves as to what CAM therapies parents are using to treat their children's asthma. By doing so, they can then take the lead in eliciting information on CAM use during their contacts with parents to ensure safety when these therapies are used, to educate parents about the advantages and disadvantages of individual CAM therapies, to provide culturally competent care, and to improve adherence to the prescribed medication regimen. If parents feel that they are part of the decision-making process regarding treatment of their children's asthma, they may be more likely to adhere to the prescribed medication regimen. Healthcare providers have an opportunity to intervene at the individual level to effect changes aimed at improving adherence to the prescribed treatment regimen through improved communication, education (both parents and themselves), and partnership with the families.