Social Determinants of Asthma and the Healthy Living, Healthy Learning, Healthy Lives Community-Based Participatory Research Project

Background/Purpose: Although asthma has historically been viewed as an individual-level disease, with individual-level causes, the condition is increasingly being recognized as the result of the complex interplay of multiple contextual and psychosocial factors. Many of these contextual and psychosocial factors disproportionally impact children who are poor, African American, and who live in socially and economically disenfranchised communities. Health Living, Healthy Learning, Healthy Lives (HL³) was formed to address the social determinants of asthma in Homewood, an economically disadvantaged, predominantly African American, “inner-city” neighborhood. The conceptual framework includes three general domains: fundamental factors (i.e. poverty, segregation), intermediate factors (i.e. neighborhood infrastructure, social environment, the physical environment), and proximate factors (i.e. exposure to violence, stressors).  This multilevel conceptual framework guides our efforts to understand and intervene in conditions that place the children who live, learn and play in Homewood at an elevated risk to experience asthma, its correlates, consequences and co-morbidities. In this paper we will discuss each of these factors within the context of Homewood, with a focus on the proximate factors that were measured in a recent neighborhood assessment.

Methods: To better understand the social determinants of health related to asthma in Homewood, the HL³ study team administered 50 surveys in the winter of 2014-2015. Survey instruments were designed by the University-Community partnership and were informed by conceptual framework and data collected in the HL3 study. Parents of children with asthma (children under 18) who live in Homewood were identified through purposive sampling from resident groups affiliated with HCV partners (Homewood Community sports, AHRCO, PPS, etc.) and invited to participate in the study, and snowball sampling was used to recruit additional families.

Results: Two of Homewood’s “fundamental” or macro-level asthma risk factors include residential segregation (95% African American) and economic inequality (40% of Homewood’s adults live in poverty and 50% are unemployed). Key intermediate-level predictors of childhood asthma disparities in Homewood include the high level of aging, vacant and abandoned properties (28% of properties are vacant) as well as poor air quality (NO₂ from 11.9-16.7 ppb). Our preliminary results from the parent/caregiver survey of children in Homewood with asthma suggest that at the proximate level, urban stressors such as being afraid to have your child go outside, having a family member be ill or injured, and getting into trouble at school, are associated with an increased frequency of asthma attacks in the past 4 weeks among children (r=.30, p<.05). Financial hardship, specifically being worried that food will run out, is also tied to an increased frequency of asthma attacks (r=.25; p<.05).

Conclusions and Implications:  Taken together, these results suggest that proximate factors tied to living in the neighborhood as well as living in poverty are closely related to children’s asthma.  They suggest that programs aimed at reducing neighborhood violence, addressing the trauma experienced by households in the neighborhood, and reducing the level of food hardship can help reduce the frequency of asthma exacerbations experienced by children in Homewood as well as other low-income neighborhoods.