Hearing the Unheard: Voices of Black Emerging Adults With Uncontrolled Asthma

Patients who identify as Black share a disproportionate burden of asthma prevalence, morbidity, and mortality relative to other racial groups in the United States. According to the Centers for Disease Control and Prevention,1Centers for Disease Control and PreventionMost recent asthma data.https://www.cdc.gov/asthma/most_recent_data.htmDate accessed: November 15, 2023Google Scholar the prevalence of asthma among patients of Black identity is 4% to 5% higher and morbidity is 3% to 4% higher than those who identify as White. These race-related health disparities affecting Black patients in the United States have existed for as long as race- and ethnicity-specific data have been collected and reported. Despite many advances in the diagnosis, treatment, and overall management of asthma, disparities persist affecting the Black population. Further compounding this disparity is the overall lack or limited inclusion of Black patients in clinical and translational research. The lack of meaningful inclusion of Black patients in asthma research leaves these patients and communities voiceless in the ability to achieve equitable opportunity for health relative to other racial groups in the United States. Qualitative research provides an important scientific avenue for including the important perspectives of patients and driving future innovation. The study published by Lee et al, "Black emerging adults with uncontrolled asthma: a qualitative study," in this issue of The Journal of Allergy and Clinical Immunology (JACI): In Practice,2Lee J.L. Ogini F. Hashmi M. Nelson B.W. Carpenter L. MacDonell K. et al.Black emerging adults with uncontrolled asthma: a qualitative study.J Allergy Clin Immunol Pract. 2024; 12: 347-354Google Scholar describes a qualitative study conducted among Black emerging adults that assessed the challenges and barriers to the asthma care experience among this understudied population. This report provides a window into the unique perspectives of young adult Black patients with asthma, an even less well-represented group in asthma research. The study reveals findings that are in line with the current understanding of asthma and asthma burden among Black patients and identifies new and key areas that allergists, health care providers, researchers, and others should consider to achieve health equity and health justice for the Black patient population. The study revealed seven major domains from the focus group interviews: Heightened Anxiety Around Asthma Management, Asthma Symptoms Interfering With School and/or Work, Asthma in Social Group Settings, Transitioning to Adulthood Leading to Increased Autonomy and Financial Independence, Use of Technology in Asthma Management, Concerns Regarding COVID-19, and Perceived Biases and Stereotypes. These domains present opportunities to consider interventions to improve asthma care and outcomes in this population. The domains identifying mental health, socioeconomic status and wealth, technology use, and the impact of bias and discrimination in the health care setting present less explored opportunities within asthma treatment models to drive future research and policy- and structural-level changes. Studies have suggested that anxiety is more common among people with asthma relative to those without the condition. In a systematic review and meta-analysis of case-control studies in asthma, investigators found that the risk of anxiety disorders was twice that among people with asthma relative to those without it.3Ye G. Baldwin D.S. Hou R. Anxiety in asthma: a systematic review and meta-analysis.Psychol Med. 2021; 51: 11-20Crossref Scopus (39) Google Scholar A study conducted among adolescent patients examined the trajectory of depressive symptoms across development and found that overall trajectories of depressive symptoms were similar between those with and without asthma. However, socioeconomic disadvantage and racial marginalization affected results, in which Black adolescents had greater baseline depressive symptoms and American Indian adolescents tended to have worse depressive trajectories into adulthood.4Ruppe N.M. Clawson A.H. Ankney R.L. Welch G. Mullins L.L. Chaney J.M. Depressive symptom trajectories across adolescence and adulthood among individuals with asthma.J Pediatr Psychol. 2023; 48: 572-582Crossref Scopus (1) Google Scholar Health care providers should consider the impacts of marginalization on some racial and ethnic populations and how these groups may experience additional mental health effects owing to marginalization. For example, chronic and toxic stress has been shown to impact those identifying as Black disproportionately within the United States, and stress related to racism has been cited as being associated with poorer asthma control among children.5Barnthouse M. Jones B.L. The impact of environmental chronic and toxic stress on asthma.Clin Rev Allaergy Immunol. 2019; 57: 427-438Crossref PubMed Scopus (61) Google Scholar Addressing mental health within the population with asthma appears to be an important component of asthma assessment and management among Black emerging adults. Allergists and health care providers should consider multidisciplinary clinical approaches to asthma treatment, which include the help of psychologists, psychiatrists, and mental health care providers. Further research should also focus on the layered biologic impacts of chronic and toxic stress and mental health in asthma. Respondents in the focus group also identified barriers related to bias and perceptions of racism within the medical environment. Experiences of bias and racism lead to distrust of health care providers and the health care system overall by Black patients and affect patient outcomes. Racial bias among clinicians has been described. A study conducted among pediatric resident trainees demonstrated that most trainees held pro-White bias and negative bias toward Black people, including Black children, and similar biases have been found among academic medicine faculty.6Johnson T.J. Winger D.G. Hickey R.W. Switzer G.E. Miller E. Nguyen M.B. et al.Comparison of physician implicit racial bias toward adults versus children.Acad Pediatr. 2017; 17: 120-126Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar,7Johnson T.J. Ellison A.M. Dalembert G. Fowler J. Dhingra M. Shaw K. et al.Implicit bias in pediatric academic medicine.J Natl Med Assoc. 2017; 109: 156-163Crossref PubMed Scopus (49) Google Scholar Racial bias within the health care system has been shown to have impacts on how patients are assessed and treated.8Goyal M.K. Johnson T.J. Chamberlain J.M. Cook L. Webb M. Drendel A.L. et al.Racial and ethnic differences in emergency department pain management of children with fractures.Pediatrics. 2020; 145e20193370Crossref Google Scholar, 9Cain M.R. Arkilo D. Linabery A.M. Kharbanda A.B. Emergency department use of neuroimaging in children and adolescents presenting with headache.J Pediatr. 2018; 201: 196-201Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 10Raman J. Johnson T.J. Hayes K. Balamuth F. Racial differences in sepsis recognition in the emergency department.Pediatrics. 2019; 144e20190348Crossref Scopus (29) Google Scholar In 2023, the American Thoracic Society removed the inclusion of race correction and race-based equations within the calculation of spirometry and pulmonary function measurement.11Bhakta N.R. Bime C. Kaminsky D.A. McCormack M.C. Thakur N. Stanojevic S. et al.Race and ethnicity in pulmonary function test interpretation: an official American Thoracic Society statement.Am J Respir Crit Care Med. 2023; 207: 978-995Crossref PubMed Scopus (35) Google Scholar Race-based medicine is currently understood to be a form of racism in medicine that was historically propagated to dehumanize certain groups of people and legitimize the oppression of those groups.12Wright J.L. Davis W.S. Joseph M.M. Ellison A.M. Heard-Garris N.J. Johnson T.L. et al.Eliminating race-based medicine.Pediatrics. 2022; 150e2022057998Crossref Scopus (33) Google Scholar Finally, bias against patients with obesity has been well-described and may further lead to intersectional impacts of bias experienced by Black patients categorized as having obesity.13Phelan S.M. Burgess D.J. Yeazel M.W. Hellerstedt W.L. Griffin J.M. van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.Obes Rev. 2015; 16: 319-326Crossref PubMed Scopus (696) Google Scholar There is a need to mitigate both explicit and implicit bias within health care. Individuals can start by engaging in education on these topics, learning strategies to counter bias in real time, and advocating for policies and practices to remove bias and racism from medicine and the medical environment.14Capers IV, Q. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education.ATS Sch. 2020; 1: 211-217Crossref PubMed Scopus (55) Google Scholar Diversification of the health care workforce will also bring important voices and perspectives to medicine to counter the integration of bias and stereotypes into how we practice. Focus group participants cited financial concerns as a potential barrier to managing asthma; as one participant cited, "Cost is, like, my biggest enemy." Emerging adults may be especially vulnerable to financial barriers because they may lose parental health insurance coverage or age out of Medicaid coverage. Black emerging adults may be especially affected by such financial barriers, given the long-standing and persistent wealth gap within the United States. Wealth is defined as the difference between the value of assets owned and the amount of owed debts. It incorporates the value of assets that are accumulated over time, including assets passed down over generations. In the United States, systemic and institutional barriers have limited the opportunity for wealth building among the Black population via numerous avenues, including federal policies such as the Home Owners' Loan Corporation Act, which sanctioned redlining, preventing Black residents from building wealth through home ownership. The 1944 federal GI Bill provided many benefits to World War II veterans that led to generational wealth among White families; however, Black veterans did not receive such benefits. Households identified as Black in the United States are reported to hold less than 0.1¢ of median wealth for every dollar of median wealth of White households, and the layered effects of the lack of generational wealth and resulting lack of benefit of that wealth hinder upward mobility for Black emerging adults.15NYC Department of Health and Mental HygieneAnalyzing the racial wealth gap and implications for health equity.https://www.nyc.gov/assets/doh/downloads/pdf/cmo/racial-wealth-gap-health-equity.pdfDate accessed: November 17, 2023Google Scholar Wealth has been linked to several observed health disparities in the United States, including asthma. A study using National Health Interview Survey found that severe asthma was associated with lower wealth, and increased wealth was protective against severe asthma.16Zagorsky J.L. Smith P.K. Does asthma impair wealth accumulation or does wealth protect against asthma?.Soc Sci Q. 2016; 97: 1070-1081Crossref Scopus (5) Google Scholar Systemic and institutional-level interventions have been suggested for reducing the racial wealth gap in the United States. Allergists can also be advocates for expanded Medicaid coverage across states as well as universal health care structures that may help to alleviate the disproportionate limitations of wealth on achieving health equity. Finally, the respondents identified potential opportunities for the expanded use of technology in managing asthma in this population. Telemedicine may provide the opportunity to address barriers such as transportation issues, time constraints, and health care provider shortages observed in predominantly Black communities and allow for remote management and regular assessment for those living in areas without access to specialists.17Lang D.M. The impact of telemedicine as a disruptive innovation on allergy and immunology practice.Ann Allergy Asthma Immunol. 2022; 128: 146-151Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Technology using digital spirometry, peak flow, adherence trackers, and wearable sensors may provide autonomy to patients to track symptoms and manage disease in partnership with health care providers in real time. This may foster further opportunities for shared decision-making and improved patient and provider interactions. Artificial intelligence-driven analytics may enable data from continuous monitoring to be used to develop more personalized approaches to asthma management and treatment, and integrating data and technology within the medical record may allow more ready identification of socioeconomic barriers. Technology within medicine also has the potential to provide more culturally relevant and better accepted platforms for education and self-management training.18Chunara R. Zhao Y. Chen J. Lawrence K. Testa P.A. Nov O. et al.Telemedicine and healthcare disparities: a cohort study in a large healthcare system in New York City during COVID-19.J Am Med Inform Assoc. 2021; 28: 33-41Crossref PubMed Scopus (169) Google Scholar Electronic health record data and individual tracking might also be considered to feed into larger databases, aiding in public health research specifically focused on asthma in Black communities and providing real-life data on asthma control and treatment responsiveness in this group for which there is a paucity of clinical trial data. The strategic implementation of telemedicine and technology in managing asthma among Black patients holds the potential for a transformative impact. This study highlights unique and important areas to consider for asthma in Black emerging adults. However, the focus group participants provide a limited scope because most were female and had received post–high school education although the income level varied. Future studies should expand to understand these initial unique domains in contrast to the current state of how we currently address asthma disparities. New voices are necessary within research, policy, and practice to direct the field toward the most relevant gaps in achieving health equity and justice. Black Emerging Adults With Uncontrolled Asthma: A Qualitative StudyThe Journal of Allergy and Clinical Immunology: In PracticeVol. 12Issue 2PreviewAsthma morbidity and mortality are disproportionately high in the Black population, especially among Black emerging adults (BEAs) (age 18-30 years). Few studies have been done to identify unique challenges to asthma care in BEAs. Full-Text PDF