Social need screenings, community programs mitigate disparities in asthma care
Click Here to Manage Email Alerts
Key takeaways:
- Social determinants of health include housing, employment, education and health care.
- 86% of children with asthma reported at least one adversity and 48% reported four or more.
WASHINGTON — By screening for unmet social needs and working with community linkage programs, providers can mitigate disparities in asthma care, according to data presented at the American Thoracic Society International Conference.
Targeted interventions can then improve health and decrease the utilization of acute health care, Adali Martinez, MD, MPH, first-year pulmonary fellow at University of California, San Francisco, said during her presentation.
“Over the last 20 years, we have made many advancements in biological precision medicine and the development of biologics that have changed the way that we treat severe asthma,” Martinez said.
However, she continued, pharmacological treatment cannot mitigate many factors that cause disparities in asthma.
“So, I want to challenge all of you to take the framework of precision medicine and apply it to public health,” Martinez said.
Social determinants of health
The biological determinants of population health include the genome, epigenome and transcriptome, proteome and metabolome, cellular processes and organ systems, as per the UCSF Office of Population Health and Health Equity.
The upstream determinants of biologic health include social and economic policies, institutions, neighborhoods and communities, living conditions and social relationships and individual risk factors, UCSF also reported.
“The intersection of precision medicine and population health must be considered in order to develop a targeted intervention for individual patients,” Martinez said.
Structural racism and discriminatory policies such as redlining, segregation and eminent domain have impacted the distribution of wealth in the United States as well as the distribution of the social determinants of health, such as housing, employment, education and health care, Martinez continued.
“That impacts and increases the risks of marginalized communities to exposures in the physical and social environments,” she said.
Direct and indirect impacts on asthma include exposure to indoor and outdoor pollutants, financial burdens and unmet social needs that influence patients’ abilities to tend to their health, Martinez said.
For example, she said, redlined communities have more exposure to indoor allergens and indoor and outdoor pollutants, with rates of asthma-related ED visits that are 2.4 times higher than other communities.
“This association is multifactorial, and not only because of these increased exposures to pollutants, but also these same areas are food deserts. There’s more food insecurity, and there’s also a lot of economic strain,” Martinez said.
Economic hardships such as an inability to borrow money or find work, not owning a home, and transportation issues impact asthma, including readmission rates for asthma-related symptoms that are more than twice as high among Black children than other populations, Martinez continued.
“These markers of hardship were more strongly associated to readmission rates than these traditional markers like income and education,” she said. “These hardships explained 41% of the racial readmission differences.”
Food insecurity and the use of food assistance programs have been associated with asthma symptom burdens as well, Martinez said, with associations between running out of food and increased odds for asthma and its associated symptoms such as wheeze during exercise and nighttime coughing.
Participating in the CalFresh supplemental nutrition assistance program in California and in free and reduced school meal programs has been associated with increased odds for symptoms related to asthma as well, Martinez said.
Screenings and interventions
“So, now what?” Martinez asked. “What do we do?”
Just as precision medicine uses molecular markers to guide asthma treatment, providers can use markers to determine which upstream determinants of population health may be affecting a family or a whole neighborhood, Martinez said.
Martinez and her colleagues created the 17-item Pediatric ACEs and Related Life-events Screener (PEARLS) in collaboration with families and providers.
The tool measures 10 adverse childhood events (ACEs) that traditionally have been included in screenings, including physical, emotional and sexual abuse; physical and emotional neglect; and household challenges such as mental illness, intimate partner violence, parental separation or divorce, incarceration, and substance misuse or dependence.
PEARLS also measures seven social determinants of health, including violence and bullying, discrimination, food insecurity, housing insecurity, family separation, caregiver illness or disability, and death of a caregiver.
Initial use of the tool revealed an association between increased adversities and lower caregiver ratings of child health as well as increased odds for missing school due to health reasons, Martinez said.
A secondary analysis found that 86% of children with asthma had experienced at least one of these related life events or adversities, and 48% had experienced four or more of them. Also, odds for severe wheezing increased by 19% and odds for wheezing with exercise increased by 16% with each additional reported adversity.
“As you go up 1 point in the PEARL screener, you have that much higher odds of these symptoms,” Martinez said.
These associations persisted after Martinez and her colleagues adjusted for inhaler adherence, she said, suggesting that traditional guidelines alone do not mitigate differences in asthma symptoms among these children.
Also, a randomized controlled trial at the University of California, San Francisco, screened 1,809 participants for unmet social needs and randomly assigned them to a control arm that received written handouts and resources or an in-person navigation program.
“The navigation intervention arm reported not only fewer social needs in the 12-month follow-up, but then also reported improved global child health in those 12 months,” Martinez said.
Subsequent investigations found no difference in ED visits for acute asthma care between the groups, but there was a decrease in hospitalizations (HR = 0.59; 95% CI, 0.38-0.94), Martinez said.
In Philadelphia, Martinez continued, the Community Asthma Prevention Program collaborated with Habitat for Humanity and other organizations to provide asthma education while addressing triggers among patients with severe and persistent asthma.
The intervention targeted dust, mold and pests in the homes of these patients, who experienced a 50% reduction in nighttime asthma symptoms, 40% reduction in rescue inhaler use and 60% reduction in missed school days after repairs were completed.
“The best result is that ED and hospital visits decreased 90% after the intervention,” Martinez said. “This is a great example of using both biologics, because we know that indoor allergens are directly impacting asthma symptoms, and also public health precision medicine.”
The Baltimore Regional Housing Partnership Mobility Program provides workshops and counseling to families as well as housing vouchers and other assistance so families can move from distressed neighborhoods to neighborhoods with less poverty. The program also follows up with families after they have moved.
Before moving, 15.1% of the 123 children with persistent asthma in the program had at least one exacerbation per 3-month period. After moving, that fell to 8.5% (adjusted difference, –6.5%; 95% CI, –11.9 to –1.7%). Maximum symptom days in the previous 2 weeks improved from 5.1 before moving to 2.7 afterward as well (adjusted difference, –2.37 days; 95% CI, –3.14 to –1.59).
“It’s showing just the impact of how you can truly target an intervention to address the downstream impacts of structural racism and policies,” Martinez said.
As these impacts have shaped social determinants of health, Martinez concluded, they have had direct and indirect impacts on disparities in asthma health.
“Precision public health integrates social, environmental and behavioral determinants of health with other omics in the development of targeted interventions,” Martinez said.
“Screening can help deliver targeted community linkage interventions, and then housing repair and housing mobility programs are ways to deliver these targeted interventions that address unmet social needs and the downstream impacts of structural racism,” she said.