Elizabeth C. Matsui|Adewole Adamson|Roger D. Peng
Time's up to adopt a biopsychosocial model to address racial and ethnic disparities in asthma outcomes
The University of Texas at Austin|The University of Texas at Austin|Johns Hopkins University
issue journal fitzpatrick et al1fitzpatrick gillespie se mauger dt phillips br bleecker er israel e et alracial disparities asthmarelated health care use national heart lung blood institutes severe asthma research programj allergy clin immunol 2019 143 20522061abstract full text full text pdf pubmed scopus 46 google scholar present results analysis data national heart lung blood institutes severe asthma research program aims understand contributions socioeconomic environmental factors racial disparities asthma outcomes followed population 631 children adults asthma among approximately one third black found black participants 2fold greater odds emergency department ed visit asthma white participants consistent national data investigators used propensity scores match white black participant populations community family socioeconomic variables environmental exposure variables found accounting factors eliminated racial disparity asthmarelated ed visits outcomes including outpatient physicians office visits asthma hospitalization differ selfreported race study highlights important issue related racial disparities asthma outcomes greater burden asthma morbidity among us black population explained large part socioeconomic environmental inequities black white populations rather racebased biology specifically genetics finding implications framing research public health population health health care delivery strategies aimed reducing ultimately eliminating disparity health care research agendas history conflating race biology emphasizing predominantly biological model disease disparities race social construct important insofar conveniently measurable proxy important factors influence health outcomes health literacy environment stress community factors social determinants health associated downstream race influential health outcomes fig 1 surprisingly grants study health care disparities disproportionately awarded study influence individual biological factors rather community societal factors2alvidrez j castille laudesharp rosario tabor national institute minority health health disparities research frameworkam j public health 2019 109 s16s20crossref pubmed scopus 210 google scholar overemphasis race biology explain health disparities perpetuated idea disparate health outcomes function individual failures genetic defects inherent systemic inequities systems perpetuate predominant framing miss critical opportunity examine intervene social environmental factors shape biology environmental exposures disproportionate among lowincome minority populations pest allergens pollution exposure3milligan kl matsui e sharma h asthma urban children epidemiology environmental risk factors public health domaincurr allergy asthma rep 2016 16 33crossref pubmed scopus 78 google scholar 4matsui ec environmental exposures asthma morbidity children living urban neighborhoodsallergy 2014 69 553558crossref pubmed scopus 49 google scholar psychosocial factors associated poverty stress well understood shape immune phenotype5wright rj cohen rt cohen impact stress development expression atopycurr opin allergy clin immunol 2005 5 2329crossref pubmed scopus 281 google scholar contribute symptoms exacerbations6wood bl brown es lehman hk khan da lee mj miller bd effects caregiver depression childhood asthma pathways mechanismsann allergy asthma immunol 2018 121 421427abstract full text full text pdf pubmed scopus 24 google scholar without sufficient attention resources paid socioeconomic environmental factors findings fitzpatrick et al1fitzpatrick gillespie se mauger dt phillips br bleecker er israel e et alracial disparities asthmarelated health care use national heart lung blood institutes severe asthma research programj allergy clin immunol 2019 143 20522061abstract full text full text pdf pubmed scopus 46 google scholar work others7beck af huang b auger ka ryan ph chen c kahn rs explaining racial disparities child asthma readmission using causal inference approachjama pediatr 2016 170 695703crossref pubmed scopus 81 google scholar suggest able shrink disparity fact made little progress regard8oraka e iqbal flanders wd brinker k garbe p racial ethnic disparities current asthma emergency department visits findings national health interview survey 20012010j asthma 2013 50 488496crossref pubmed scopus 82 google scholar despite decades focus issue wide availability highly effective medications although study highlights important concept helps illuminate path forward area asthma disparities methodologic considerations arise conceptual framing various factors involved hypothesized causal relationships particular ambiguity factors confound relationship race ed visits factors might lie causal pathway race ed visits making clear distinction 2 classes factors critical study design perspective also implies different analytic approaches present analysis uses propensity scores adjust factors confounders implies socioeconomic environmental factors confound causal relationship selfreported black race asthma ed visit risk briefly propensity score matching statistical technique used make 2 populations compared similar respect known characteristics example one population might higher proportion men comparison population propensity scores applied weight contributions men women population contributions population similar however might plausible hypothesize socioeconomic environmental factors fact result selfreported black race factors actually lead increased risk ed visit asthma fig 1 conceptualization relationship black race asthmarelated ed visits mediated socioeconomic environmental factors although propensity score modeling play role mediation analysis approaches principal stratification counterfactual mediation models specifically designed allow estimating causal effects intermediate factors appropriate analysis9vanderweele explanation causal inference methods mediation interaction1st ed oxford university press oxford2015google scholar logical conclusion current work given framing environmental socioeconomic factors confounders difference ed visits race adjust factors hence racial disparity therefore problem solve result reframing socioeconomicenvironmental factors mediators observed racial disparity exist operates variety socioeconomic environmental pathways question factor intervene mitigate disparity break causal pathway race ed visits one genuine potential confounder genetics could affect ones race well ones propensity asthma ed visits genetic markers african ancestry also cause increased risk asthma exacerbations linked polymorphisms cause asthma exacerbations fig 1 thus genetic factors available would need adjusted perhaps propensity scores therefore careful conceptual framing underlying causal pathways essential designing analyzing studies focused asthma among minority populations asthma racial disparities results informative effective looking future study inform approach research area leads advances minority health racial ethnic disparities asthma outcomes foundational step expand framing issue asthma disparities one mostly biologic one explicitly considers environmental psychosocial economic factors10king dw hurd tc hajek ra jones la using biopsychosocial approach address health disparitiesone persons visionj cancer educ 2009 24 s26s32crossref pubmed google scholar applying biopsychosocial rather biologic model disease adopting model would help protect explicit implicit focus biology race distracts likely important social determinants health end research programs experts disparities race ethnicity socioeconomics behavioral health environmental health involved planning design execution interpretation studies partnership communities build interventions also key affected communities bring expertise scientific community given lived experiences consideration factors mediate relationship race asthma outcomes inform study design data collection data sets developed secondary analyses linking data across sectors outside health education housing built environment important strategy ensuring environmental psychosocial economic factors examined addition interpretation study results incorporate roles socioeconomic factors environmental exposures might playing example factors might explain observed associations biology asthma disparities biology asthma outcomes among minority populations adopting biopsychosocial model asthma implications stages research across translational spectrum simple task given findings study fitzpatrick et al1fitzpatrick gillespie se mauger dt phillips br bleecker er israel e et alracial disparities asthmarelated health care use national heart lung blood institutes severe asthma research programj allergy clin immunol 2019 143 20522061abstract full text full text pdf pubmed scopus 46 google scholar others failure reduce racial disparities asthma emphasizing biologic model worth effort racial disparities asthmarelated health care use national heart lung blood institutes severe asthma research programjournal allergy clinical immunologyvol 143issue 6previewdespite advances asthma care disparities persist black patients disproportionally affected asthma also poorer outcomes compared white patients fulltext pdf