By Ryan N. Walker, MD, MPH, and Suhani Bora, MD
Dr. Walker is a third-year family medicine resident at Lawrence Family Medicine Residency, completing an area of concentration in integrative medicine with a focus on obesity management.
Dr. Bora is the director of the the Integrative Medicine Fellowship at Greater Lawrence Family Health Center/Lawrence Family Medicine Residency.
• This cross-sectional study aimed to assess the relationship between chronic stressors and asthma control in 31 African-American children 1 to 6 years of age in Kansas City, MO.
• Results showed a statistically significant inverse correlation between Test for Respiratory and Asthma Control score and stress from racism, with a P value of 0.02.
SYNOPSIS: This cross-sectional study of African-American children 1 to 6 years of age (n = 31) in Kansas City, MO, finds a statistically significant inverse correlation between asthma control (measured by Test for Respiratory and Asthma Control in Kids score) and stress from racism.
SOURCE: Jones BL, Staggs V, Woods-Jaeger B. Chronic stress exposure among young African American children with asthma. Ann Allergy Asthma Immunol 2019;123;507-508.
It is well established that asthma control depends on several different social determinants of health (SDOH), including built environment, socioeconomic status, and access to healthcare.1 More recently, racism has been identified as playing a role in SDOH.2 National data illustrate racial disparities in asthma morbidity and mortality among children of color compared to non-Hispanic white children.3
The authors conducted a cross-sectional study to assess the relationship between chronic stressors and asthma control in pre-school aged and younger African-American children located in Kansas City, MO. The parents of 31 African-American children 1 to 6 years of age in a Head Start program completed questionnaires to assess chronic stressors and asthma control.
The chronic stressors assessed were home and caretaker instability (housing/caregiver instability), food insecurity (the six-item United States Food Security Scale), racism/discrimination (the Schedule of Racist Events), neighborhood disorder and violence, family abuse/violence (Expanded Adverse Childhood Experiences [ACE]), parental depression (Patient Health Questionnaire), and issues related to urban life (Crisis in Family Systems). Asthma control was assessed using either the Asthma Control Test (ACT, n = 11) or the Test for Respiratory and Asthma Control (TRACK, n = 20). Results were significant for an inverse correlation between TRACK score and stress from racism (P = 0.02). All other comparisons were found to be nonsignificant.
The authors recognized that limitations of the study include a small sample size and the use of parent experience from questionnaires as a proxy of the child’s lived experience, which introduces measurement bias. On the other hand, using parent experiences as a tool of intergenerational trauma and its effect on asthma is interesting.
The study design in and of itself is a limitation. As a cross-sectional study, researchers are able to assess only the status of asthma at one point of time. A prospective study, although more time-consuming, would have provided additional information regarding the change in asthma control and stress factors and how this compares with a control group.
Furthermore, there is a question of generalizability, given the study takes place in one city and participants were all from the Head Start program. Those factors introduce selection bias and possible confounders. With all questionnaires, there is the potential of response bias. However, the study does not include the response rate.
An argument also could be made that the age range of participants is too large, given vast developmental differences in that age group. More specifically, the age range introduces the need to use two different questionnaires to assess asthma control — TRACK, which is for persons 5 years of age or younger, and childhood ACT, for ages 4 to 11 years.4,5 For patients 4 to 5 years of age, it is unclear which questionnaire was used and how this was determined.
Despite the limitations, this study builds on emerging research of the effects of racism on asthma. Clinicians taking care of Black children should consider the connections between chronic stressors, racism, and asthma control. They may consider incorporating screening for social determinants of health or adverse childhood experiences into their clinical workflow (assuming they have adequate behavioral health and community support within their clinical settings to adequately manage a positive screen at the time of the clinical encounter). More to the point, healthcare providers should consider the effect of racism and adverse childhood events and be aware of, and collaborate with, community resources and mental health agencies to address the many factors that contribute toward managing childhood asthma. Clinicians may consider taking active roles in advocating for anti-racism within their institutions and in their communities.
- Woods ER, Bhaumik U, Sommer SJ, et al. Community asthma initiative to improve health outcomes and reduce disparities among children with asthma. MMWR Suppl 2016;65:11-20.
- American Public Health Association. Racism and health. https://www.apha.org/topics-and-issues/health-equity/racism-and-health
- Centers for Disease Control and Prevention. Uncontrolled asthma among children, 2012-2014. Updated July 3, 2019. https://www.cdc.gov/asthma/asthma_stats/uncontrolled-asthma-children.htm
- Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory and asthma control in kids (TRACK): A caregiver-completed questionnaire for preschool-aged children. J Allergy Clin Immunol 2009;123:833-839.e9.
- Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol 2007;119:817-825.
- Krieger N, Smith K, Naishadham D, et al. Experiences of discrimination: Validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med 2005;61:1576-1596.
- Carlson S, Borrell LN, Eng C, et al. Self-reported racial/ethnic discrimination and bronchodilator response in African American youth with asthma. PloS One 2017;12:e0179091.
- Harnios CE, Bastos JL, Campbell ME, et al. Measuring perceived mistreatment across diverse social groups: An evaluation of the Everyday Discrimination Scale. Soc Sci Med 2019;232:298-306.