Asthma, Health and Society: A Public Health Perspective

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Meredith Barrett , PhD, is vice president of science and research at Propeller Health , a health technology company working to reduce the burden of asthma and chronic obstructive pulmonary disease COPD. Leaders in Louisville, Kentucky, know first-hand that where you live and work affects your health and well-being. Asthma is one of the most common and costly chronic diseases in the United States, affecting more than 8 percent of the U.

Asthma also leads to more than 13 million missed days of school and 10 million missed days of work, negatively affecting educational achievement, employee productivity and regional business growth. But the most frustrating part is that a large proportion of these hefty impacts could be avoided with improvements in self-management, community policy and advances in digital health care. Triggers of asthma are well-known —allergens, mold, dust, smoke.

Kentucky has the fourth highest adult asthma prevalence in the US But unlike most communities facing this kind of burden, leaders in Louisville recognized the tremendous potential of innovative, data-driven collaborations to address these challenges. Louisville built a map of asthma combining citizen-powered, digital therapeutics and open data. These data were then de-identified and combined with more than 40 socioeconomic and environmental data layers, and hotspots of high asthma inhaler use were identified. In this proof-of-concept pilot, we showed that collecting real-time, geographically explicit data on asthma is incredibly valuable for individuals, for their doctors, for local decision-makers and for the community at large.

Now an unprecedented collaboration is about to take place with a single, unified agenda: reduce the burden of asthma.

Poor urban environments are characterized by a higher concentration of indoor and outdoor air pollution, reduced availability of green spaces and less access to healthy foods — in addition to psychosocial factors — aspects of urbanization and modern urban life that are associated with asthma 2.

This is consistent with our results of an inverse relationship between human development, measured by HDI, and prevalence of wheezing. We can postulate that investment in human capital, in addition to economic capital, may affect the distribution of risk factors for asthma. It is expected that more equitable societies devote resources to creating less hazardous environments, promoting healthy behaviors, and also investing in education and health prevention and promotion. In this way, the investment in human development would determine the extent to which people are able to avoid the risk of asthma morbidity.

A Public Health Perspective

According to our results, the effect of socioeconomic determinants is partially produced by environmental variables. Higher household water supply, lower sanitation and crowding were related to asthma prevalence at the intra-level analysis. Despite the apparent contradiction of this finding according to the hygiene hypothesis, improvement in living conditions is related to an increase of atopic asthma.

Certainly, Latin America is undergoing an important process of urbanization and development; however it is far from uniform, therefore the extremes of wealth and poverty coexist in the region.

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Since asthma is not a single entity, and there are different mechanisms and risk factors for atopic and nonatopic asthma 25 , the overlap of these different immunological profiles in the Latin American context is expected Another measure of stress, the homicide mortality rate, was associated to asthma in the bivariate analysis.

Relative deprivation is a stronger predictor of the homicide rate, and it was assumed to reflect disruption of community organization, weak social controls and a lack of social cohesion Exposure to community violence is one marker of psychosocial stress, but it is also a marker for neighborhoods with a concentrated disadvantage where people could be exposed to physical or social conditions that contribute to the development of asthma or exacerbate its symptoms and even interfere with its treatment Various studies identified an association between community violence and asthma prevalence, as well as hospitalizations and emergency visits 27 , 28 , Our results are in line with other studies showing a correlation between asthma prevalence and indicators of social inequality 14 and national income level In the latter the authors reported a bimodal distribution of asthma symptoms, higher in high- and low-income countries, and lower in middle-income countries.

While some factors could predominate in low income countries, others are more relevant in high income ones. In this last group, where the atopic phenotype predominates, the hygiene hypothesis may have been shown to be more adequate to explain the high prevalence Our previous analysis performed in the younger group year-olds evidenced a strong association between Gini index, environmental variables and health related variables, including infant mortality rate and homicide rate and asthma prevalence In the group of year-olds included here, the Gini index effect was shared with the HDI, reflecting the importance of the level of inequality of societies as the level of community wellbeing.

In young children, the asthma prevalence was more correlated with proximal factors such as living conditions and health conditions, however, in adolescents the prevalence was predominantly correlated with structural factors. Thus, distal factors may be partial proxies of country socioeconomic level and cultural differences, and can represent a variety of global factors with the potential to have some effect on asthma occurrence, like dietary intake patterns and tobacco smoking prevalence Also, distal factors may determine the extent to which poor communities concentrate physical and social disadvantages, with the usual impact on the disease occurrence Some studies have described the potential role of climate conditions on asthma prevalence and other allergic diseases, showing that extreme temperature and rapid decreases in temperature can increase the risk of asthma attacks However, we found a weak association between the levels of temperature and wheezing, which may be due to the use of the annual mean temperature, once monthly or daily data were not available for all the participating centers in the study period.

Furthermore, it is important to consider other environmental factors linked to global climate change, especially in urban settings.

Asthma, Health and Society: A Public Health Perspective

Environmental pollution would affect air quality through several pathways, including traffic-related pollutants 32 , dust and production of allergens Some of these pollutants could cause respiratory disease or exacerbate asthma symptoms in susceptible children, especially in urban environments. In this way, in developing countries from Latin America, higher pollution levels were correlated to wheezing, allergies, bronchitis and pneumonia This study has several strengths, such as the use of a validated measure of asthma symptoms provided by the ISAAC through a standardized protocol, and the addressing of potential determinants of asthma prevalence in a region as large as Latin America, using urban centers as units of analysis.

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The ecological approach is appropriate to examine the effect of the economic, social, and environmental exposure factors on health, especially if environmental causes of illness are sought A weighted regression method was used which gave appropriate relative importance to the variables and allowed us to obtain parameters that were more accurate and in the expected direction. The results should be interpreted with caution, especially because relationships between factors at the ecological level may not be the same as at the individual level, and we cannot adjust for individual confounding factors.

However, some of the variables introduced in our analysis are exclusively ecological ones, such as the Gini index and HDI, operating exclusively at the population level. Thus, their effects are not restricted to the poor, but extend to all social strata, and thus are expected to be shared by all members of the society An additional limitation is related to the lack of information on air pollution and annual variation of temperature for the participating urban centers at the time of the asthma data collection, factors that play a role on the burden ofthe disease.

Finally, the prevalence of wheezing in the past 12 months is a measure that is very correlated to severe asthma, and it is possible that the pattern of social and environmental determinants observed is more concerned with severe and uncontrolled asthma than with asthma prevalence.

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Save 40% on select Business & Management books + FREE shipping or 50% on Physics eBooks! Editors: Harver, Andrew, Kotses, Harry (Eds.) Most up-to-date resource on managing asthma from a public health stance. This readable text of pages takes a public health perspective of asthma. Its emphasis is on the social systems in which individuals live and.

The high burden of disease observed may be the result of a set of interrelated adverse social situations, in which the access to diagnosis and preventive care is fundamental to achieving adequate disease management and crisis prevention. In conclusion, this ecological analysis has explored some social and environmental factors providing evidence of the potential influence of poverty and inequalities on current wheezing among adolescents in a complex social context such as Latin America.

In recent decades, the region has been experiencing a rapid process of urbanization and internal migration, reflected in disorganized urban growth leading many people to live in poverty and in stressful urban environments.

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The growth of disadvantaged neighborhoods coexists with different degrees of urban development compared to the most privileged areas. The transformation of urban spaces is accompanied by changing lifestyles and hence environmental exposures, with a consequent impact on lung development and immune response 38 , In Latin America, the non-atopic asthma phenotype is dominant but the frequency of atopy is also high and is expected to increase as the living conditions of populations improve.

Therefore, the findings from this cross-sectional ecological analysis could reflect the complex dynamic of asthma and allergies in this region of the world From a public health perspective, we consider it important to approach the structural determinants of health and contextualize exposure factors which make individuals more vulnerable to develop and aggravate asthma symptoms.

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Recognizing some of the limitations of ecological studies, we consider it important to explore these relationships in greater depth, incorporating the different phenotypes of asthma, through a multilevel approach. Thorax ; Asthma in Latin America: a public health challenge and research opportunity. Allergy ; Gold DR, Wright R. Population disparities in asthma.

Annu Rev Public Health ; Atopic sensitization and the international variation of asthma symptom prevalence in children. Asthma cases in childhood attributed to atopy in tropical area in Brazil. Respiratory symptoms and home environment in children: a national survey.

Book Asthma Health And Society A Public Health Perspective

Identification of population subgroups of children and adolescents with high asthma prevalence: findings from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med ; Prevalence of and factors associated with current asthma symptoms in school children aged and year old in Bogota, Colombia. Pediatr Allergy Immunol ; Sensitization to dust mites as a dominant risk factor for asthma among adolescents living in central Virginia.

Multiple regression analysis of a population-based study. Socioeconomic deprivation and asthma prevalence and severity in young adolescents. Eur Respir J ; Socioeconomic status, stress, and immune markers in adolescents with asthma. Psychosom Med ; Which population level environmental factors are associated with asthma, rhinoconjunctivitis and eczema?

Resp Res ; Ecological study of socio-economic indicators and prevalence of asthma in schoolchildren in urban Brazil. BMC Public Health ; Social determinants of childhood asthma symptoms: an ecological study in urban Latin America. J Commun Health ; International correlations between indicators of prevalence, hospital admissions and mortality for asthma in children.

Int J Epidemiol ; Hoffman K, Centeno MA. The lopsided continent: inequality in Latin America. Annu Rev Sociol ; Mortality, the social environment, crime and violence. Sociol Health Ill ; Influence of climate factors on emergency visits for childhood asthma attack. Pediatr Int ; Diurnal temperature range and childhood asthma: a time-series study.


In other projects Wikimedia Commons. Marmot, eds. Global Health Initiative was created in by President Obama in an attempt to have a more holistic, comprehensive approach to improving global health as opposed to previous, disease-specific interventions. Dupilumab efficacy and safety in adults with uncontrolled persistent asthma despite use of medium-to-high-dose inhaled corticosteroids plus a long-acting beta2 agonist: a randomised double-blind placebo-controlled pivotal phase 2b dose-ranging trial. You will be notified by email within five working days should your response be accepted. Depending on the need, environmental health officers or public health inspectors , bioethicists , and even veterinarians , gender experts, or sexual and reproductive health specialists might be called on. Another is the control of tobacco smoking.

Environ Health ; Income inequality and population health: a review and explanation of the evidence. Soc Sci Med ; Income inequality and social dysfunction. A matter of life and breath: childhood socioeconomic status is related to young adult pulmonary function in the CARDIA study. Inequality in income and mortality in the United States: analysis of mortality and potential pathways. BMJ ; Emerg Themes Epidemiol ; Asthma in Latin America: the dawn of a new epidemic. Curr Opin Allergy Clin ; Am J Public Health ; Exposure to community violence is associated with asthma hospitalizations and emergency department visits.

J Allergy Clin Immunol ; Community violence and childhood asthma prevalence in peripheral neighborhoods in Salvador, Bahia State, Brazil. National income, self-reported wheezing and asthma diagnosis from the World Health Survey. The hygiene hypothesis in allergy and asthma: an update. Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan.

Environ Health Persp ;