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Running Head: ASTHMA IN URBAN ENVIRONMENTS 1

Asthma in Urban Environments

Inequalities in Healthcare: Brownsville Disparate Rates of Asthma

Professor Kathleen Falk

NUR 4110

November 3, 2017


Introduction

Asthma is an inflammation of the airways in the lungs that ultimately causes difficulty

with breathing. It can be life-threatening and interfere with an individual’s life. According to

Malik, Kumar, and Frieri (2012), the urban environment has an increased risk for the

development of asthma due to pollution, exhaust from vehicles, crowded living conditions,

infection and bioterrorism. Inequalities in healthcare such as socioeconomic status and access to

care influences the rates of illness such as asthma. Asthma is most prevalent among African

Americans and those with a low social economic status with incomes less than $15,000 (Malik et

al, 2012).

This topic is important because asthma, which is a serious medical issue is prevalent in

urban environments. It is also important because Brownsville, an urban environment is

dominated by mostly African American habitants and has a remarkable amount of people with

asthma not only due to their environmental factors but also their socioeconomic status and access

to health care. This topic is significant because this shows that an area that has environmental

concerns with barriers to healthcare will produce major health disparities in comparison to the

rest of the population. The risk factors such as the environment and socioeconomic issues needs

to be addressed and managed to decrease the disparate rates of asthma in Brownsville.

Targeted group

Brownsville, according to community health profiles (2015), has a total population of

86,377 people. It is composed of 76% blacks, 20% Hispanics and 1% whites. The health issue

that has mostly impacted this group of people is asthma. Asthma is responsible for many

hospitalizations among both children and adults. The rate of children hospitalized because of


asthma is twice the rate of Brooklyn and city wide with adult hospitalization more than twice the

rate in Brooklyn and citywide (Community Health Profiles, 2015). The people in Brownsville

has an increase in hospitalization due to poor management of their health. This can be due to

their hazardous environment or lack of insurance.

Asthma also impacts this targeted group by affecting their mortality rate. African

Americans are twice as likely to die from asthma than whites (Das, 2007). There is an increase in

mortality rates for minorities living in low income communities diagnosed with asthma. This

health issue also causes this targeted group of people to have asthma attacks at a rate of 40%

higher than whites and experience symptoms associated with asthma such as wheezing,

breathlessness, chest tightness and coughing during nighttime and early morning (Das, 2007).

This health issue is causing a decrease in quality of life of the residents in Brownsville. They are

not able to live a comfortable life and instead is living a life filled with stress and repeat

hospitalizations and ultimately death.

Challenges and barriers

There are many challenges and barriers in tackling this issue. One of the many challenges

includes the home environment. According to Community Health Profiles (2015), 73% of houses

in Brownsville have at least one maintenance defect including water leaks, cracks and holes,

inadequate heating, presence of mice or rats, and peeling paint. Many homes in Brownsville are

poorly maintained. Poor housing conditions can contribute to the development of illnesses such

as asthma. Butz, Kub, Bellin, and Frick (2013) indicated that poorly maintained homes can be a

primary source of allergens and irritant. Repeated exposures to allergens and irritants can

increase sensitization and cause asthma. Allergen sensitivity and exposure are both associated

with an increase in asthma morbidity.


Another challenge and barrier that we encounter in tackling this issue is the

environmental hazards. Brownsville has the highest level of the most harmful air pollutant PM2.5

than Brooklyn and New York City. Brownsville also has more tobacco retailers with the

percentage of current smokers in Brownsville at 14% (Community Health Profiles, 2015). This

poses a challenge because air pollution and smoking create outdoor air pollutants that can cause

asthma or an asthma attack. This will increase hospitalization and even cause death.

A third challenge and barrier that we face is health care access. Eighteen percent of adults

in Brownsville are without health insurance (Community Health Profiles, 2015). This is an issue

because these individuals are not going to a primary care physician and receiving follow up

appointments. For those who have asthma, they will not be able to obtain proper treatment and

education about their condition. According to Butz et al (2013), minorities with low income

families may find it difficult to access the health care system due to the long wait times,

availability of appointments and lack of access to specialty asthma care.

An additional challenge and barrier are the amount of income. one out of six adults 16

years and older is unemployed in Brownsville and over half of the residents in Brownsville

spend more than 30% of their monthly gross income on rent (Community Health Profiles, 2015).

The residents of Brownsville suffer from a lack of money which makes it difficult for them to

access health care and obtain resources that will promote their health and prevent illness. The

cost of asthma medication is too high. The mean out of pocket cost for asthma medication for a

child is $151 (Butz et al, 2013). This can cause non-compliance with medication leading to poor

asthma management. Time can also be a barrier where parents do not have time to take their

children or themselves to the doctor because they are constantly working to provide for their


family. Low income can lead to depression and stress which can ultimately lead to poor

management of asthma (Butz et al, 2013).

Other barriers include language, cultural and educational barriers. Thirty percent of

Brownsville are foreign born, 9% have difficulty with English, 18% are college graduates and

53% completed high school. These barriers can prevent people from understanding ways in

which to manage asthma and the severity of it. It can also prevent them from reading and gaining

knowledge themselves or inhibiting them from using the computer to apply for health insurance.

It can also interfere with adherence of treatment plans such as not taking medication due to side

effects or worrying about being addicted. They can also have a misunderstanding of the whole

treatment plan for asthma and the role that medications play in treating it (Butz et al, 2013).

Search of the literature

Low-income communities of color have a significantly higher rate of asthma than the

other communities. The quality of care that the African Americans receive such as the proper

medication, information on asthma triggers and specialty care for asthma differs from the quality

of care that the white receives even though they had similar insurance status, age, education and

employment status (Das, 2007). Here we can see that there is an injustice and inequality when it

comes to caring for different races. There is no reason why people with the same insurance,

education and employment status should receive different care.

Minorities receive poorer quality of care regardless of their ethnicity, immigrant status,

literacy level or socioeconomic status. Quality of care can still be an issue even if minorities

have access to care. This can be due to the patient not understanding the instructions given by the

doctor, cultural barrier or the bias of the physician towards the patient. Minorities are also more


likely to be seen by a general doctor rather than an asthma specialist who provides better care

when it comes to asthma (Bryant-Stephens, 2009).

According to Alicea-Alvarez, Reeves, Lucas, Huang, Ortiz, Burroughs, and Jones (2016),

the reasons why health disparities in urban communities of low-income residents are not reduced

is because there is a lack of framework and community engagement in finding out their exact

health care needs. Alice-Alvarez et al (2016) found that health and environmental programs

where the community was involved in had greater success than programs that were bought into

the community from the outside. This could reduce health disparities, improve access to care and

prevent disease because when the community is engaged, they are able to participate and arrange

the programs to their liking according to their cultural and specific community needs.

According to Bekar, Halpern, Lamb-Parker, Steele, and Shahmoon-Shanok (2014), low-

income families in urban areas may find it difficult to maintain their home environment due to

lack of money. They may not be able to afford to buy air conditioner and purifiers as well as

replace carpets. With low-income also comes stress which can suppress the immune system and

cause asthma or an asthma exacerbation and low adherence to treatment plans. Bekar et al (2014)

also found that the more educated parents were, the more likely they were to report asthma cases

in their home. This can signify that those with a lower education level are not able to report

asthma cases due to the lack of knowledge of asthma as a disease and the symptoms it presents.

Individuals who have a low socioeconomic status, are more likely to adopt unhealthy

behaviors such as smoking. Although they do not have a lot of money, they will use smoking as

a form of pleasure to cope with their daily stressors. Some of the stressors that the disadvantaged

people deal with are discrimination, higher prevalence of negative life events such as

unemployment, struggling to make ends meet and living in disadvantaged neighborhoods.


Giving up their unhealthy habits will limit them from adopting healthy behaviors (Pampel,

Krueger, and Denney, 2010). This is because they will most likely replace it with something else

to help them cope. It is also not good because smoking increases the chances of one obtaining

asthma.

According to Corburn, Osleeb, and Porter (2006), in Central Brooklyn, asthma is the

primary cause for emergency room visits, hospitalizations and missed school days in children.

Corburn et al (2006) also noted that both the physical and social characteristics of neighborhoods

including but not limited to the poverty, residential segregation, lack of transportation and high

crime rates are responsible for the overall physical health of the individual. Malik et al (2012)

found that children with asthma has three times the increase of medical expenses than those

without the disease. Children under 2 years of age with asthma were most likely to have repeated

ED visits after their asthma problem was managed.

According to Armstrong, Putt, Halbert, Grande, Shwartz, Liao, Marcus, Demeter, and

Shea (2013), African Americans have higher levels of health care system distrust (HCSD),

meaning that they do not trust the health care system. This is partly due to previous experiences

they had of racial discrimination. Armstrong et al (2013) found that when they altered the

experiences of racial discrimination, HCSD among African American decreased but did not have

any effect when they controlled for other characteristics such as health care access and

residential segregation. African Americans may not want to go to the doctor not only because

they do not have insurance but also because they have experiences of discrimination, which

deters them from seeking care.

Increased asthma hospitalizations other than environmental factors are also related to

health insurance status, access to preventive care and the use of medications. Many times when


children get hospitalized for asthma, they do not receive education on ways to prevent another

exacerbation (Claudio, Stingone, and Godbold, 2006). Holsey, Collins, and Zahran (2013)

indicated that children have higher asthma rates than adults. In low-income communities, if

children receive culturally tailored information about asthma, their knowledge increased, and the

rates of hospitalization and emergency department visits decreased.

Potential interventions

Sweet, Polivka, Chaudry, and Bouton (2014) discuss a home-based asthma intervention

called the “healthy homes intervention”. This intervention focused in low-income homes with

children with asthma in an urban setting. Sweet et al (2014) wanted to know how this

intervention will affect the severity of asthma, the caregiver’s quality of life, asthma triggers and

the management of asthma. This intervention took place from January 2008 and December 2011.

Those who participated in the intervention were referred through various sources such as

by the local children’s hospital, doctor’s office, social workers and word of mouth. After the

participants were chosen, a registered sanitarian came to the homes of the participants and

completed a home assessment, identifying asthma triggers and safety hazards. The registered

sanitarian recorded her data using a checklist and a space where she could put any comments she

had. During this initial home assessment, the sanitarian administered a baseline questionnaire to

the family. After the completion of the home assessment, participants were visited by the

program’s Public Health Nurse or the health educator. Their role was to provide the participants

with information on disease management related to asthma.

After, the visit by the Public Health Nurse and the education the participants obtained,

they were given educational materials consisting of a binder that had a “Healthy Homes Action


Plan”. They were given information about asthma triggers and the safety hazards they found in

the home during the assessment. The nurse went over the “Healthy Homes Action Plan” with the

caregiver using verbal instruction as well as demonstration. The nurse also made sure to go over

with the caregiver information about their child’s medication as well as the signs to look for

when symptoms are starting to worsen.

As part of the intervention, participants received many supplies to aid in the decrease of

allergens and asthma symptoms. Some of the many items they received were bedding supplies,

cleaning kit, safety supplies and pest control materials. In addition to receiving items for the

home, participants also had repairs made to their homes. Some of the many repairs included

installing/repairing bathroom vents, fixing/installing handrails. Removing mold and repair

broken furnaces. Repairs were only made in homes and not apartments. Letters were sent to the

owner of the apartment discussing what needed to be fixed.

Participants had a follow-up visit at the two-week mark and the four-week mark. They

had an education visit as well as a phone call. After six months, participants received a follow-up

questionnaire over the phone by the Public Health Nurse. The questionnaires assessed the quality

of life of the caregiver and presence of household triggers. The results of the study concluded

that the severity of asthma symptoms decreased drastically. There was a decrease in waking up

in the middle of the night and an increase in the caregiver’s quality of life.

Advocating for change

There are policies that can be in place to help urban communities address asthma rates

and inequalities experienced by people in the community. Policies for uninsured people should

include a census every year to calculate the number of uninsured families in the neighborhood. It


should reduce cost of insurance and the amount of contributions from each family regardless of

the family size. It should make exceptions for children with pre-existing and new cases of

Asthma when it comes to cost (Service at no cost) and should emphasize in providing more

services for families with low income, little to no education and with limited levels of

understanding of the English language.

For housing policies, they should mandate owners, landlords, and management to

periodically enforce the usage of exterminators to properly address the issues with mice, roaches

and pest in each apartment building. It should properly inspect each building prior to occupancy

to ensure that they are safe and secure for occupants. It should enforce heavy sanctions upon

building owners, landlords and management agencies that fail to abide by the standards of a safe

environment. It should provide safe housing where families with young children as well as

people with pre-existing asthma conditions would take precedence in the selection.

For policies for the environment, they should create smoke free zones and limit the

access of heavy duty trucks, vans, and commercial vehicles near school zones and

neighborhoods with high rates of Asthma. Traffic should be redirected at certain hours of the day

such as rush hours in the morning and in the afternoon to limit the exposure to toxic fumes.

For Policies on education, they should make mandatory in all elementary and grade schools the

distribution of booklets providing information on various form of assistance available. they

should have in all the bus stops pamphlets and forms to inform the residents of the services

available near them. They should have a Center of Help to assist and guide members of the

community according to their specific needs.


Summary and conclusions

The Urban environment has all if not most of the ingredients to cause the people living in

them to develop various illnesses. One disease that the urban environment is most likely to cause

is asthma. This is partly due to factors such as inequalities in healthcare that the minorities who

dominate these urban communities have. They must deal with poor housing conditions, racial

inequalities, high amount of air pollution and lack of access to healthcare. All of these factors

increase the chances of this community developing a chronic and deadly disease called asthma.

The Epidemic of cases of Asthma in Brownsville can be put under control only if the

right policies are in place with a collective effort from the elected officials as well as leaders in

the community as they engage and become more proactive in finding solutions to tackle the

existent problem. More and more families of minority groups are becoming significantly affected

daily due to the lack of resources as well as the area in which they live. Due to the lack of those

who are educated as well as the lack of awareness in the community, those who are affected are

not seeking the proper help. There needs to be a well thought of and elaborate plan to diminish

the levels of polluted air and Tobacco smoking in areas where low-income families reside.


References

Alicea-Alvarez, N., Reeves, K., Lucas, M.S., Huang, D., Ortiz, M., Burroughs, T., & Jones, N.

(2016, August). Impacting health disparities in urban communities: preparing future

healthcare providers for “neighborhood-engaged care” through a community engagement

course intervention. Journal of Urban Health, 93(4), 732-743.

Alina Das. (2007). The asthma crisis in low-income communities of color: using the law as a tool

for promoting public health. New York University Review of Law and Social Change, 31,

273-911

Armstrong, K., Putt, M., Halbert, C., Grande, D., Schwartz, J., Liao, K., Marcus, N., Demeter,

M.B., & Shea, J.A. (2013, February). Prior experiences of racial discrimination and racial

differences in health care system distrust. Medical Care, 51(2), 144-150.

Bekar, O., Halpern, E., Lamb-Parker, F, Steele, M., & Shahmoon-Shanok, R. (2015). Asthma

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care to inner-city children with asthma. North American Journal of Medical Sciences,

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Community health profiles: brownsville. (2015). Retrieved from

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https://www1.nyc.gov/assets/doh/downloads/pdf/data/2015chp-bk16.pdf


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