Nationally, the highest rates of asthma-related deaths and hospitalizations are among low-income minority adults, but most existing research doesn't focus on these patients. In particular, studies may not investigate patients where they live, in complicated, difficult circumstances. Many adult asthma patients have multiple diseases and exposure to tobacco smoke, but much research reflects the convenience of recruiting patients in clinics and on the relative simplicity of studying patients who do not have accompanying diseases such as hypertension, diabetes, and obesity.
A new study analyzes patients at ground level, drawing on reports from community health workers who visit asthma patients at home, where extreme living conditions such as poor housing, neighborhood violence, and lack of social support impose steep barriers to public health care, as well as to high-quality research. The research team argues that home visits offer a fuller understanding of how the social environment of asthma patients impacts their overall health.
Researchers from the Community Asthma Prevention Program (CAPP) at Children's Hospital of Philadelphia (CHOP) and the Perelman School of Medicine at the University of Pennsylvania describe those challenges in a study in the December 2016 issue of the Journal of Allergy and Clinical Immunology. The authors focused on 301 adults living in low-income Philadelphia neighborhoods who were prescribed an inhaled corticosteroid for asthma and required oral steroids for an exacerbation and/or had an emergency or inpatient visit within the last six months.
Community health workers visited patients in their homes and found 71 percent rented, with many living in one-room apartments or overcrowded spaces with multiple family members. Many patients also live in typical Philadelphia rowhomes, which were built in the late 19th century and are difficult to maintain on a limited income. These patients are routinely exposed to common indoor asthma triggers, such as rodents, roaches, and mold. Only 25 percent of people who participated in the study were currently employed either part or full-time. Community health workers reported their impressions of these stark, and sometimes bleak, living conditions:
- "It's not just the finances, it's the violence, lack of education and job opportunities."
- "Homes are in poor repair. Some are just unlivable."
- "Depression survey seems to trigger a lot of emotions. Often patients are crying as we try to complete it."
"Many of these patients start to feel a sense of hopelessness, especially the very sick," says Tyra Bryant-Stephens, MD, corresponding author and medical director of CAPP at CHOP. "They feel there is very little possibility of changing their current living situation, which includes poor housing, exposure to violent crime, and limited access to transportation. Some of these living conditions make it difficult or impossible for patients to get to their medical visits, which results in a further decline of their health."
Living in a high-stress environment encourages many patients to continue smoking, despite knowing it contributes to their asthma symptoms. Twenty-eight percent of those surveyed admitted they currently smoke. Other issues community health workers encountered were low education rates, limited access to healthy foods, and poor general health; 58 percent of patients had hypertension and 32 percent had diabetes.
"Medical personnel no longer make house calls, so this research gives us a view of how poverty, unfavorable home conditions, and lack of social resources limit patients' ability to access healthcare," says Andrea J. Apter, MD, MSc, MA, principal investigator of the study and Chief of the Section of Allergy & Immunology at the Perelman School of Medicine at the University of Pennsylvania. "Without the knowledge of these barriers, health providers do not have the information needed to create a tailored and empathetic approach to asthma management."
Bryant-Stephens adds, "As long as there is poor housing, health disparities will continue to exist, despite medical advancements being made in the fight against asthma. The issue is not limited to Philadelphia and needs to be addressed on a national scale. Without addressing poor housing, we will never be able to truly eliminate disparities in outcomes among adult asthma patients."
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Tyra Bryant-Stephens et al, Home visits are needed to address asthma health disparities in adults, Journal of Allergy and Clinical Immunology (2016). DOI: 10.1016/j.jaci.2016.10.006