Communication and understanding keys to asthma treatment
Cultural and socio-economic factors can be obstacles to asthma care

Beth Klements, MS, APRN, BC, provides instruction to a camper at the 2003 Boston Asthma Camp.

Despite increased asthma education efforts, state-sponsored asthma management initiatives, and safe and effective medications for prevention and control, asthma continues to be the most prevalent chronic childhood disease in the U.S. In New England, it affects one in eight children.

Healthcare providers can often experience frustration about the patient and patient families’ lack of adherence to medical advice regarding medications or other asthma management measures. Many asthma symptoms and most asthma-related hospitalizations and emergency room visits could be avoided with basic preventive care, but patients and their families often under-utilize the resources available to them, making their asthma a far more serious condition.

While Ruchi Gupta, MD looks on, campers at the 2003 Boston Asthma Camp learn to properly take their asthma medication. The camp is a partnership between Children's Hospital Boston and the Boston Public Health Commission. For more information, call the Asthma Prevention & Control Program at (617) 534-5966.

The problem may be due in large part to cultural or socio-economic issues. A recent study by the New England Asthma Regional Council confirmed that asthma and its consequences continue to disproportionately affect the poor, as well as black and Hispanic families. According to the study, children from families with a household income of less than $25,000 are almost twice as likely to have asthma than children from families with household incomes of more than $75,000. In addition, asthma rates are 50 percent higher in black and Hispanic families than in white families.

With the highest incidence of asthma in those cultures and socio-economic levels, healthcare providers have a responsibility to consider the cultural influences and lifestyle situations that may impact a family’s willingness or ability to participate in preventive care, says Amy Burack, RN, Community Asthma Program manager at Children’s Hospital Boston.

“Clinicians should be aware of the cultural, financial and environmental obstacles that asthma patients may face so they can promote better communication and trust between the patient and provider,” says Burack.

Obstacles to treatment and prevention can include poor and old housing that may be infested with mold, mildew, and cockroach droppings, which have been found to be a particular threat to children with asthma. Often the lower-income patient’s obstacle to preventive care is a lack of transportation to the doctor or pharmacy, or a lack of health insurance or funds to pay for medications and follow-up appointments. Due to financial hardship, many families seek healthcare only when they have an emergency.

“When poverty is a factor and their children appear to be well, families often have little choice but to spend money on food or other necessities, rather than medications or co-pays,” says Beth Klements, MS, APRN, BC, asthma nurse specialist in Medicine Patient Services at Children’s. “So it’s up to healthcare providers to let parents know that it’s vital to maintain daily control of asthma, especially when their child is feeling well and not displaying symptoms.”

Talking about asthma Use simple, clear language Repeat important messages Communicate important information in more than one way Give patients and their parents written material in the family’s primary language Ask if anything about the asthma management plan concerns them Ask what might make it easier for them to follow the prescribed management plan Emphasize the need for preventive care, even when symptoms are not presen

Cultural issues can also stand in the way of adequate care. In some cultures, people with a chronic illness like asthma are viewed as weak, which discourages parents from seeking appropriate care. In addition, some cultural traditions, such as burning incense or using herbs to treat illnesses, may not be embraced by Western medicine, but may be an integral part of a family’s culture.

“It’s important that healthcare providers show respect and regard for the cultural traditions that motivate these families, but strike a balance with Western medical treatments,” Burack says.

For instance, in some Latino cultures, asthma is viewed as a “cold” illness, treated by hot liquids, so physicians can suggest taking asthma medications with hot tea or broth to maintain patients’ comfort level regarding medical treatment.

Education during an office visit can be time-consuming, but will generally improve adherence to treatments. Taking an extra minute or two to ask families what they understand about asthma, and to learn what their environment and situation are like can be helpful in determining the best course of treatment. At each visit talk about the importance of preventive asthma care using simple, clear language. Give patients written material in the family’s primary language for reinforcement. Promote family involvement and ask the family and patient if they have any concerns about adhering to treatment. Ask what would make it easier for them to follow the prescribed management plan. “Develop a partnership with the patient and family,” Burack says, “and at every visit emphasize that there will be a next visit and further refine the responsibilities of both patient and provider. With communication sensitive to the unique issues that face poor and urban children with asthma, pediatricians may be able to decrease the incidence of asthma-related emergency room visits and hospitalizations each year.”

	For more information call Beth Klements at (617) 355-1928.