Asthma places significant burdens on patients, healthcare providers and the community as a whole. Nowhere is this burden more evident or difficult to alleviate than in minority and low-income children found in inner-city areas of major metropolitan areas like Chicago and New York. Studies have shown that asthma morbidity and mortality is significantly higher among children in these highly-populated areas.1,2 This increased prevalence is thought to be multi-factorial, but factors such as demographics, socioeconomic status, environmental exposure, cultural differences, and access to care are all thought to play a role.
Among children in urban environments, those of certain ethnicities and those living in poverty are found to have disproportionately higher rates of asthma. According to a CDC survey, asthma prevalence in non-Hispanic white children was 8.2%. This compared with 14.6% of non-Hispanic blacks and 18.4% of Puerto Rican Hispanics. Children living below the poverty line also had increased prevalence at 11.7%, compared to 8.2% of children living above the poverty line.3 Further investigations into the asthma disparities of our inner-city poor and minority children have revealed a complex and dynamic interaction of genetic, environmental and socioeconomic variables. Appropriate medical management is essential to controlling asthma symptoms, but some other potentially addressable areas, such as access to quality care, housing conditions, cultural differences in health behaviors, and psychological comorbidities in child and caregivers also can be important in preventing future exacerbations.
The Role of Respiratory Care Practitioners
Respiratory care practitioners (RCPs) have an important role in prevention when caring for children with asthma in any urban environment. The RCP should not be solely concerned with administration of bronchodilator therapy and peak flow monitor teaching. Although these are important interventions in the acute management of asthma exacerbations, the RCP also must be able to assess clinical, environmental and psychosocial factors, address deficiencies in patient and/or family education, and coordinate for the complete asthma care of these patients. Without comprehensive and high quality care from a specialized healthcare professional familiar with respiratory disease and the associated challenges in this special patient population, these patients are at high risk of going or returning to the local hospital emergency department (ED) for worsening or recurrent symptoms.
Practitioners must be aware of the many barriers faced in treating poor and minority children and be prepared to deal with these challenges appropriately. Cultural beliefs, cost of equipment and medications, environmental issues related to inadequate housing, and the effect of stressful life events experienced by both children and parents are just a few of the obstacles the RCP and healthcare team will face in controlling these patients’ symptoms.
The RCP working at a typical inner-city hospital will have a high rate of contact with these patients in the ED and on the floors, placing the RCP in a favorable position to improve the health and decrease the rate of recurrence of these patients. Often, the RCP will have the opportunity to provide more detailed and individualized patient education than the ED physician or nursing staff. Given their specialized training and knowledge of respiratory disease, they have the ability to serve as an important patient advocate and can be a crucial link to asthma management resources available in the community. If a child requires hospital admission for his or her asthma, the child and family become a captive audience for the RCP working the pediatric floor. RCPs will have multiple opportunities during the child’s stay to further explain triggers, medications and monitoring, as well as emphasize and discuss follow-up care. The well-prepared RCP can navigate the barriers to quality asthma care for these patients and be an effective provider of vital education and resources that might prevent the patient further suffering and burdensome healthcare utilization. The following are some important considerations for the RCP and some possible approaches to dealing with or avoiding these barriers to asthma management.
Cultural competence results in improved quality of care.
Differences in cultural beliefs regarding disease origin, appropriate treatment and the importance of follow-up can offer unique challenges in providing quality asthma care. Studies have shown that policies that support cultural competence are associated with higher quality asthma care for children.4 It is important to talk with your patient’s family and facilitate a discussion that is open and accepting of their cultural beliefs. Some cultures have preconceived ideas about disease and treatment, and great care should be taken to inquire about these ideas before discussing the purely medical aspects of asthma. Although little evidence may exist to prove that one cultural practice is more or less effective than standard treatment, it is never a good idea to argue with families over their beliefs.
For instance, a mother may feel that cold temperatures are causing her son’s wheezing and she insists on dressing him in multiple layers or has him avoid going outside. A discussion with mom about how protecting the child from the cold will become increasingly harder as he gets older and more independent might be more useful than trying to explain the mechanism of bronchoconstriction in exhausting detail. Instead, recommend using the medications to make him “stronger,” so that if he does choose to take off his heavy coat he’ll still be protected. This approach does not discredit her ideas about cold weather but instead allows you to work within her belief system while still delivering appropriate medical care. Your time is always better served gaining knowledge about their cultural beliefs and finding a way to make your suggested treatment fit within that framework. Most of the time, an accord can be reached. Always ask what your patient and family know about their disease and ask what they think makes it better or worse. Don’t waste time refuting their explanation. Merely encourage them to utilize the methods and medications available and assure them that other patients have found relief from the therapies being recommended.
Be aware of financial concerns in your patients.
Respiratory medications are expensive, and cost often can be a significant barrier to adherence, especially in your patients without insurance or sufficient income to cover prescription co-pays. Be aware that some patients may be reluctant to admit they are having difficulties, so remember to ask if they are having trouble purchasing medications. The average monthly costs of some commonly prescribed inhalers are as follows: albuterol MDI, $49; fluticasone MDI (lowest strength), $48; fluticasone/salmeterol diskus 100/50, $201.5 Even though most children have access to insurance with prescription coverage, many of these medications are not available as generic, and co-pays still can be difficult to afford.
Children with asthma often have parents or siblings with asthma, and inhalers might be shared between family members. Ask about others with asthma in the home and keep this in mind when thinking about the child’s actual inhaler usage. Most pharmaceutical companies do offer discount programs for those in need, but the application process can be tedious and some programs must be applied for online, so computer access is required. Websites such as www.needymeds.org and www.pparx.com (Partnership for Prescription Assistance) offer access to multiple discount programs if the patient does have computer access. Special programs may be available in your city, such as mobile care vans, coalitions, and other public health programs. If so, share information on these programs with your patients’ families, as they may qualify for important assistance.
Home-based interventions can significantly improve your patients’ lives.
The Task Force on Community Preventive Services has recommended home-based, multi-trigger, multi-component, environmentally-focused interventions for asthmatic children and adolescents.6 This is based on evidence that these programs, such as the CDC’s Healthy Homes (www.cdc.gov/HealthyHomes), improve asthma symptoms and decrease days of missed school. If your health department doesn’t offer a program like this, at least give the patient a copy of a “healthy home” checklist and go through some of the things they can do around the house to decrease triggers (e.g., eliminate smoking in the home, reduce mold and pests, or repair holes or cracks in walls and floors). Advise your patients to fix what they can, but be sure to recommend nontoxic cleaning methods and responsible pest control methods like the EPA’s Integrated Pest Management program (www.epa.gov/pesticides/factsheets/ipm.htm). Store-bought “bug bombs” have potential harms and should be discouraged.
Some poorer patients may live in extremely questionable, inadequate or unsafe housing. Recommend seeking assistance for more difficult pest problems or structural concerns. Although environmental interventions can have a great impact on a child’s asthma, this is an area that can be extremely difficult to remedy, especially in inner-city housing, as responsibility ultimately is in the hands of landlords and building owners. Encourage families to be patient, but persistent and instruct them to contact their local housing authority if unsafe conditions exist.
Mental health can play a significant role in asthma control.
Psychological stress has been linked to asthma severity found in urban communities.7 As a healthcare provider, you must be aware of the effect that mental health might have on adherence and disease severity. Inner-city children can be exposed to more violence or trauma and tend to have higher rates of posttraumatic stress disorder (PTSD) symptoms and anxiety.8 This can sometimes present like an asthma attack or can complicate an ongoing asthma exacerbation. Patients with depression often have difficulty with medical adherence and might not take medications as prescribed. The parent’s mental health can also affect the child’s symptoms, since they are responsible for administering medications to younger children. Parents or children who are found to have unaddressed mental health concerns should be referred for proper treatment.
There are mental health resources in the community that can be accessed by those in need, most of which your facility’s social worker, chaplain or mental healthcare professional will be able to provide information about. Of course arranging for behavioral health treatment falls far outside of a typical RCP’s job description and may be very difficult to address, but for the family who seems to be living at the hospital or continually stuck in the ED because of their child’s uncontrolled asthma, it can mean all the world. Taking the extra time to confer with nursing or the physician when you notice signs of depression or anxiety (i.e. flat affect, inappropriate or inconsolable crying, excessive worrying or panic) can ultimately change the long-term course of the patient’s disease. Asthma can be a chronic, life-long disease and a patient or family member receiving treatment for his or her mental health disorder will be better equipped to cope with the added stress of living with a chronic disease.
Excessive hospitalizations and ED visits are indicators of poor asthma control and/or poor follow-up care.
In 2010, 10.2 million children living in the U.S. had an asthma-related ED visit in the last 12 months.9 Many inner-city families utilize ED services as their sole means of managing their child’s asthma. This becomes problematic for the healthcare system that often goes without reimbursement for these visits. Ultimately, it is the child who suffers most though, since adequate follow-up is rarely sought out and the child continues to experience symptoms that could be controlled with the proper treatment and monitoring.
Patients admitted to the ED or hospital inevitably will encounter an RCP. As mentioned previously, this interaction serves as an excellent teaching moment for both patient and family. Families are often more receptive in the face of their child’s worsening symptoms. It’s a great time to educate and reinforce proper use of rescue and controller medications, the importance of eliminating triggers in the home and, most importantly, the need for adequate, timely follow-up. A standard report describing the patient’s current visit and discharge instructions can be sent to the patient’s follow-up physician if one has been identified. If the patient has no primary care physician, social services can be instrumental in coordinating public aid and arranging for the patient to be seen at a community health center.
With proper medication, adequate follow-up, and the tools for self-management, families can reduce excessive healthcare usage. RCPs, with their specialized skill set and dedicated time, play a vital role in helping break the cycle of “frequent flyers” to the ED.
Asthma care requires a multidisciplinary approach.
Many of the strategies to manage asthma in poor and minority children living in inner-city areas require cooperation of various departments and disciplines, but RCPs are certainly at the center of the acute management of the asthma exacerbation. That being said, they also can serve as key coordinators for comprehensive asthma care and must work directly with nurses, physicians, other healthcare workers, and public health organizations to get these patients the quality care they need. Emergency and respiratory departments must work together to ensure that all children are managed appropriately, according to the Expert Panel 3 Guidelines for the Diagnosis and Management of Asthma.
A thorough review of all patient handout materials can help identify areas for improvement in information accuracy and cultural competence. Written asthma action plans are an essential piece of patient education and should be provided to all asthmatics. A list of identified community resources also can be generated to provide families a starting point for seeking assistance in their neighborhoods. Working closely with social services can be of benefit when trying to identify community resources and arrange for public aid or follow-up for the uninsured or under-insured.
Given the complexity of genetic, environmental and psychosocial interactions seen in asthma, treatment must be comprehensive and individualized for every patient, especially in the underserved pediatric populations in our inner-city neighborhoods. RCPs and other clinicians must keep in mind that biological variations in responses to medical treatment exist and, in addition, remain cognizant of the multitude of factors that can affect a patients’ adherence and disease severity. Asthma is a chronic disease that if treated appropriately and monitored diligently can be controlled. RCPs can be a crucial part of not just the management of the acute exacerbation, but the management of the long-term disease. By providing culturally competent, comprehensive asthma care and ensuring patients and their families are properly equipped to handle future recurrence of the disease, RCPs can help reduce the significant burden asthma places on inner-city children, families, healthcare systems, and the community.
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5. “Familymeds Online Pharmacy.” Online Pharmacy, Over the Counter (OTC), and Health & Better Beauty Store. N.p., n.d. Web. 14 June 2012. <http://www.familymeds.com/>.
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Matthew Greve, BS, RRT, is a registered respiratory care practitioner at United Hospital System, a 4th-year medical student at Rush Medical College and a founding member of the Kenosha-Racine Asthma Coalition.