Low income populations and minorities experience disproportionately higher morbidity and mortality due to asthma. The reasons for these disparities are not clearly understood, but where poverty is present they are probably due to an interaction of factors including: lack of access to quality medical care, high levels of exposure to environmental allergens and irritants, language barriers, and lack of financial resources and social support to manage the disease effectively on a long-term basis.
African American and Hispanic children appear to be at especially high risk of not receiving adequate preventive treatment for asthma attacks. Several studies have documented inappropriate treatment for asthma among inner-city children with asthma (64, 81, 82, 83). For example, an analysis of preschool children hospitalized for asthma found that only seven percent of African Americans and two percent of Hispanics, compared with 21 percent of white children, were prescribed routine medication to prevent future asthma exacerbations (82). A recent study of elementary school children in Baltimore, MD and Washington, DC, found that inner-city children with asthma frequently are undermedicated, using the wrong medication, or none at all despite daily symptoms, frequent school absences, and emergency room visits for asthma. More than 80 percent of those who did take regular medication did not use anti-inflammatory drugs (64) .
Inner-city children and their parents often live in highly challenging, difficult environments. Families often face economic uncertainty and live in homes or apartments with poor ventilation and high allergen levels. Children in these settings frequently have multiple caretakers for their asthma and little continuity of health care (84) . A study of Hispanic families in San Diego found that parents who speak only Spanish have significantly more misconceptions about asthma than English-speaking Hispanic parents (85). Although not as well studied, children with asthma from rural America also face multiple barriers that adversely affect their health including extensive poverty, geographic barriers to health care, less health insurance and poor access to health care providers (86).
Current DHHS Activities: Eliminating Disparities
The asthma objectives for Healthy People 2010 emphasize the need to reduce the disproportionate impact of asthma on minorities, particularly with regard to asthma death rates and hospitalization rates. Several DHHS agencies support public health programs designed to meet the needs of individuals and families in poverty. The NAEPP supports several such programs, and CDC's Z AP Asthma and other Regional programs described earlier have a particular focus on improving the lives of inner-city children. The Administration for Children and Families' (ACF's) Head Start program offers comprehensive early childhood education, nutrition, and health and social services, along with strong parent involvement, to low-income children nationwide. Caring for children with asthma is addressed in two important training guides used by Head Start front line staff, management teams, and parents. The Office of Minority Health (OMH) supports the "Minority Health Asthma Attack Avoidance Education Program," which is designed to increase awareness of asthma triggers and ensure appropriate referral to medical care.
The majority of DHHS funds dedicated to asthma provide direct health services to underserved populations. The Medicaid program administered by HCFA reimbursed costs of asthma care for over one million low income patients in 1995 (65). The Health Resources and Services Administration (HRSA) -supported Health Centers and the National Health Service Corps programs aim to increase access to comprehensive primary and preventive health care and to improve the health status of underserved and vulnerable populations. Comprehensive primary care services in Health Centers include the treatment of asthma; in 1998, patient visits for asthma exceeded 600,000 (87). The Indian Health Service (IHS) delivers health care to American Indians and Alaska Natives. In addition to providing asthma treatment as part of standard care, IHS has helped to establish several specialty clinics focused on asthma.
HRSA is also working with non-governmental institutes (co-sponsored and endorsed by the NAEPP) to develop and apply an innovative model to accelerate improved asthma care. The care model uses five basic elements to improve care: 1) collaboration between the health system and community organizations and agencies, 2) patient/family self-management, 3) support to enable clinicians to use guidelines in their every day work, 4) practice re-design, and 5) information systems to track individual patients as well as assess the health of the asthma patient population in the medical practice. HRSA and other organizations are supporting a number of community health centers in adopting this model of care, which involves a 12-14 month training program for health center teams.
Inner-City Asthma Study
The NIAID-sponsored National Cooperative Inner-City Asthma Study found that empowering families to increase their asthma self-management skills and to improve their interactions with the primary care physician were important ways to improve quality of care and reduce asthma symptoms. An asthma counselor helped not only with asthma education, but with problem solving tailored to the families' needs. Improvement in health continued at the same level during the second year of the program when the asthma counselor was no longer involved (84).
Various DHHS agencies and institutes conduct research to better understand the impact of asthma on vulnerable populations. NIEHS and NIAID sponsor research on community-based strategies to reduce exposures that trigger asthma in economically disadvantaged and/or underserved populations as in their National Cooperative Inner-City Asthma Study. Six of the eight NIEHS/EPA/CDC- sponsored Centers for Children's Environmental Health and Disease Prevention Research have projects focusing on asthma in under-served populations. NHLBI and NIAID support genetics research that is revealing that multiple genes may be involved in asthma, and early findings indicate that they may vary among ethnic/racial groups. The NIH Office of Research on Minority Health and NHLBI are also supporting a study of Genetics of Asthma in Hispanics. NHLBI and NINR sponsor research on the effectiveness of asthma education and self-management programs, targeting African Americans and Mexican Americans in both urban and rural areas.
Several DHHS agencies conduct research and evaluations to assess and improve both access to, and quality of asthma care. The Agency for Healthcare Research and Quality (AHRQ) supports research designed to measure and improve the quality of health care, reduce its cost, and broaden access to essential services . HRSA collaborates with AHRQ on the development of health center practice-based research networks. One of these projects is focused on asthma and involves epidemiologic investigations, clinical outcome studies, and intervention trials. HCFA conducts research on the use of services and expenditures for asthma care provided to its Medicare and Medicaid beneficiaries. Specific work includes examining the quality of asthma care - using the Guidelines - provided to Medicaid eligible children. NHLBI and NIAID support demonstration and education research to develop innovative, culturally-sensitive approaches to teaching asthma management strategies to African-American and Hispanic children and their families.
Urgent Needs: Eliminating Disparities
If we are to make progress in eliminating disparities, it is critical to investigate why these disparities exist. While the "Urgent Needs" described in the previous sections will help to address the disproportionately high impact of asthma on minority and low-income populations, more focused efforts are also needed. DHHS will seek a substantial expansion of public health programs to eliminate the disproportionate burden. The Department will accelerate research directed at the reasons for disparities and the means to reduce these impacts . Four key priorities include:
Promote wider use of current knowledge to diagnose and manage asthma, focusing on minority and low income populations. Programs that help health care providers practice up-to-date asthma care, educate patients and their families, expand asthma control activities beyond the home, -- all need to be targeted toward special population groups hardest hit by asthma. In doing so, such programs need to address the unique circumstances of the particular community. A high priority is to implement education programs that take into account the complexities of poverty, language barriers, and cultural sensitivities.
Improve access to quality care. DHHS agencies must work in public/private partnerships to address the barriers to quality asthma care and provide ongoing, comprehensive, quality health services for asthma. Such services would be based in the community and would encourage active participation of families, while addressing their cultural needs. A policy of collaboration at the local level and coordination of services among community providers (including health, environmental, and housing services) are important ingredients for success.
Expand research on asthma in special population groups. While data indicate greater hospitalizations and deaths from asthma among population groups such as Hispanics and African Americans (4, 88), additional research is needed to understand the reasons for these higher rates. For example, research is needed to understand if these disparities are due to more severe disease in these populations or to differences in health care practices and access to care, or a combination of both. One research priority is distinguishing the roles of environmental, socio-economic, cultural and genetic factors in contributing to asthma severity. Genetics research will help explain different risks for severe asthma and differences in response to asthma treatments. This can help identify new therapeutic approaches. Exposures to environmental allergens and pollutants may be greater for some population groups, particularly in the inner city. Research is needed to design interventions that could reduce asthma severity by addressing these environmental factors. In addition, some Hispanic populations appear to have a markedly elevated risk for developing asthma. Environmental, genetic and cultural factors need to be examined to understand why these differences occur. Finally, as prevention strategies for asthma are developed and tested, their effectiveness in different population groups should be a special focus for evaluation.
Investigate access to care and evaluate quality. Another priority is to better understand the degree to which individuals in poverty, particularly children, have access to care and whether the quality of that care is sufficient. Recent studies reveal that traditional measures of access (e.g., insurance coverage and source of routine care) may not reflect the realities affecting poor health outcomes for asthma. The National Cooperative Inner-City Asthma Study reported that 92 percent of children in the study were covered by insurance, and nearly three quarters were covered by Medicaid. While most families reported a usual source of routine care (neighborhood or hospital clinic), more than 50% of respondents found it difficult to get follow-up care. Quality of care was deficient and participants were unlikely to have continuity between usual sources of routine (follow-up) and acute care (23). Further studies are needed to uncover the barriers to improved health, including: access to quality and continuous care and access to prescription medication and delivery devices. Analyses must continue to evaluate the impact of managed care on delivery of health services and health outcomes.