An Analysis of Asthma Among Black Americans Using the PRECEDE-PROCEED Model

Abstract

This paper explores the relationship between asthma and Black Americans through the PRECEDE-PROCEED model of health. The paper first explores the prominent diseases within the black population and then explains the significance of asthma in terms of symptomology, risk factors pertaining to the population, as well as comorbidity between asthma and other diseases prominent in the black population. Behavioral and environmental factors are explored followed by an analysis of available resources and policies. Finally, a dual intervention is proposed; the intervention would target parents and children to educate them about asthma as well as the importance of social support for children.

Among the diseases prevalent among the black population, such as diabetes, hypertension, and obesity; Black Americans have some of the highest asthma rates in the country (CDC, 2018). Asthma is a chronic respiratory disease which often begins in childhood, can be triggered by environmental irritants and is worsened by certain health behaviors (CDC, 2016). A lack of health education regarding asthma may result in missed school days, increased risk of emergency room visits and errors in emotional/physical perception (Ashley, Freemer, Garbe, & Rowson, 2017; Shields, Comstock, & Weiss, 2004; CDC, 2012). Although many health organizations have created plans to improve asthma statistics, Black Americans are still over twice as likely to develop asthma than White Americans (CDC, 2018); therefore, improvement in health interventions for Black Americans is necessary. Using the PRECEDE-PROCEED model, data will be used to better identify behavioral and environmental needs, preexisting and enabling factors, and current and possible resources which may be implemented into a more successful intervention plan.

The PRCECEDE-PROCEED model was developed as an all-encompassing planning model, divided between a research/planning phase (PRECEDE) and an action phase (PROCEED) (National Cancer Institute, 2015). The model analyzes behavioral and environmental, internal and external, and predisposing, enabling, and reinforcing factors. The model begins with a social assessment of the community's perceived needs and is then followed by an epidemiological assessment to prioritize these needs. A behavioral and environmental assessment then researches internal and external factors relating/contributing to the issue. This is followed by an educational and ecological assessment which examines predisposing, enabling, and reinforcing factors. The next step, administrative and policy assessment, begins the second phase of the model and looks at the availability of resources, organizational policies/ regulation that impact the intervention. The final four steps deal with implementation and evaluation of health promotion intervention (National Cancer Institute, 2015, p.41).

According to the CDC (2017), Black Americans have higher rates of premature morbidity from all causes than White Americans; morbidity rates escalate the earlier a disease emerges. Certain health disparities, such as heart disease, diabetes, obesity, smoking, HIV/AIDS, and drug overdose; have prominent associations with Black Americans; however, the risk of a Black American developing asthma is over twice as likely compared with a White American (CDC, 2018). Further, other black health disparities, such as obesity and smoking, are strongly associated with asthma risk (CDC, 2016). An epidemiological study from 2001-2010 showed that black children's rates of asthma grew at almost a 4% yearly rate (Akinbami, Moorman, Simon, & Schoendorf, 2014). The study also showed that black children were almost twice as likely to have at least one asthma attack in the past year and over 7 times as likely to die from asthma compared with white children.

There are many internal and external factors which contribute to asthma development and aggravation. Internal factors consist of biological predispositions/ resistance to medications, beliefs about asthma severity, symptom detection/alexithymia (not being able identify and describe feelings), stress levels, and emotional/social stability. Black Americans had biological predispositions which showed a decreased response to asthma medications (Gamble, et al. 2010; Akinbami, et al. 2014). Beliefs about asthma, in other words not taking asthma seriously, may contribute to poor symptom detection which may contribute to the development of alexithymia. Stress levels contribute to internal irritation which can lead to asthma development or an asthma attack. Emotional stability relates to stress and may be a result of one's home/school environment.

External factors which contribute to asthma were exposure to violence, quality of living/work environment, family/ethnic support, living with a single mother, and living with a smoker. Exposure to violence and living with a single mother were both found to be most relevant to black children (Barile, Edwards, Dhingra, & Thompson, 2015). Violence may be found within one's home as well as within one's community. Quality of living/work environments are strongly tied to socioeconomic status both of which are often of poor quality for black individuals. According the United States Census Bureau (2017) Black Americans were the most likely to have only a high school diploma and had the second highest rate of unemployment and poverty. People with lower socioeconomic status (SES) are also more likely to be exposed to toxic living environments such as air/water pollution as well as poor work conditions which are conducive to asthma (Institute of Medicine, 2001). Health-related issues to economic instability included stress, sensory impairment, limited educational achievement and adult morbidity/mortality (Knopf et al., 2016). This implies that not only does low economic stability during childhood affect the individual, it may perpetuate the same problem to the next generation. Finally, smoking is a health disparity related to Black Americans (CDC, 2017). Smoking affects air quality and aggravates the lungs of asthmatics, increasing the likelihood of asthma development and attacks (CDC, 2016).

Predisposing factors related to asthma were poor asthma knowledge, perception of severity, overall asthma attitude, self-efficacy, and perception of responsibility. A lack of knowledge about asthma can lead to other predisposing factors such as overall attitudes about asthma, severity perception, and possibly self-efficacy (Hopkins Tanne, 2001). Self-efficacy and responsibility perception relate to the performance of maintenance behaviors (Bruzzese, 2012). Enabling factors were available policies/resources which led to a lack of education and influenced asthma perception, transportation, and living/working conditions. Getting access to education may be difficult due to transportation issues and limited resources. Reinforcing factors were family/community support, having a primary doctor, and self-perception. Having social support will aid in performing preventative and maintenance behaviors. Communicating effectively with one's doctor also aids in reinforcement of positive behaviors (Chiang, Huang, & Lu, 2003).

After collecting behavioral/environmental data, the two points deemed to be most critical were a lack of asthma education and a lack of social support. Many Black Americans do not have regular doctors, which may relate to their poor levels of, and access to, medical care and information (Hopkins Tanne, 2001). Black Americans are not properly educated on asthma symptomology and therefore may not realize they are suffering from asthma symptoms until symptoms become severe. Further, black children were almost 65% less likely (than white children) to have a follow-up after having an asthma-related emergency room experience (Shields, Comstock, & Weiss, 2004). Many of these problems could be solved with effective asthma education (Hopkins Tanne, 2001). Other ramification of a lack of education also manifested in asthma maintenance behaviors. An inverse relationship was found between age and asthma management in black adolescents (Bruzzese, 2012). The older children were, the less likely they were to effectively schedule taking medication, recognize trigger symptoms, or get help. Although there was a positive correlation with age and perceived responsibility, this may be the result of a disconnect between independence and self-care. This suggests that children with asthma need ongoing education on self-management. Further, mismanagement has been associated with depression, anxiety, (likely related to medical cost and perceived control) and dyspnea (labored breathing which will can make asthma worse) (Baiardini, Sicuro, Balbi, Canonica, & Braido, 2015). The other factor targeted by this intervention is social support. Many risk factors of asthma related to a lack of social support such as violence, stress, alexithymia, and low SES (Bellin et al., 2014; Ashley et al., 2017; Baiardini et al., 2015; Akinbami et al., 2014), whereas a significant protective factor is family/ethnic pride (Koinis-Mitchell et al., 2012). A study by Barile et al. (2015) showed that adverse childhood experiences were associated with lower emotional support, which was associated with a lower health quality of life. Additionally, the study found that low income and high unemployment was associated with lower emotional support. Finally, the study stated that adverse childhood experiences could prevent children from developing social relationships into adulthood. Therefore, childhood environment plays a large role in a child's development and potential. By limiting environmental factors like exposure to education and social support, a child's abilities may be compromised.

The proposed intervention will be divided into two components, an educational component and a support component. Each component of the intervention will be geared toward children and parents, with differing curricula. Two different education groups will be administered as parents and children will be taught separately. The first component will be administered in order to educate the target population on asthma severity, prevalence in Black Americans, risk factors, and the importance of maintenance. Maintenance includes (parents) scheduling doctor's appointments as well as (children) conducting self-assessment. Self-assessment includes monitoring trigger and asthma symptoms as well as taking medication consistently and responsibly. An effort will be made to explain that one's independence (as they age) means being their own doctor. Additionally, asthma education will include the benefits of performing protective behaviors, such as fewer emergency room visits.

The second part of the intervention deals with social support for children. A lack of social support, especially in an environment of violence, can create or exacerbate asthma. Further, children who had a lack of social support have shown to increase in likelihood of developing into an adult with a low SES (Barile et al., 2015). Parents will be taught about the importance of family support and strategies to use inside the home, while ethnic clubs will be offered as a way for children to learn about and take pride in their heritage while making friends. This will create a resource for children in which they celebrate their differences, instead of hiding them, which will increase pride and minimize discrimination. Additionally, children will learn coping techniques that can be used during times of inflammation/isolation. Research by Baiardini et al. (2015) showed that asthmatic people who learned effective coping skills showed less psychological morbidity, greater perception of control, and better disease management. It is also important to look for negative coping efforts, such as avoidance which may indicate risk of emotional instability.

This program will take place in community centers in the tri-state area (New York, New Jersey, and Connecticut) which should be easily accessible to community members. The tri-state area will be the preliminary location of the intervention due to its diversity in education, income, and culture (United States Census Bureau, 2009). The educational and support programs will be bi-weekly programs which will alternate programming (between the two components) based on the week; the program will last for four months. However, the children's clubs (support component for children) will be held weekly. Each component will be taught by a qualified black professional (a black doctor will teach the educational component, a black psychologist/social worker will teach the social support component, and a black cultural educator will be in charge of ethnic clubs) as race may also serve as an additional barrier to asthma education or implementation of positive asthma behaviors (as they will better understand their audience's cultural needs).

In order for program effectiveness to be measured, data will be collected during the first, eighth, and final week of the program. Data will be used for formative and outcome evaluation. Data collection will consist of qualitative and quantitative data. Participants will be given surveys (Perceived Support Scale, Brief-Coping Orientation of Problem Experienced (COPE) inventory scale) to fill out as well as have a saliva test to test relevant biomarkers (cortisol and C-reactive protein). It is anticipated that this intervention will yield improvement of >15% over baseline over the course of the program. Improvements of a lesser scale will be further interrogated for variables that may require modification for ideal success. If the program produces significant results, the program will expand to other states across the country. Where applicable, the program will be tailored to account for unique variables (i.e. travel, participant disability) to maximize success. Further, there will be continuous yearly follow-ups to make sure programs are still being run appropriately while still proving effective, which will be used for impact and process evaluation. Instructors as well as community/civic center staff will be evaluated on their maintenance of the program in accordance with intended implementation; further, yearly data reports of the program will be analyzed to assess the program's standing and possible need for refinement. The only resources necessary for this intervention are a community center and black healthcare professionals. Because this is purely an educational intervention it should not conflict with any legislation.

Although this study provided an in-depth analysis of relevant factors in asthma development and exacerbation, certain environmental factors like poverty were not explicitly part of the intervention plan. The intervention aids in education, which is often a limited resource as a result of poverty; however, asthma education will not help improve one's living or work conditions. Because the environmental conditions and legislature for each state is different, certain organizations are recommended as resources in order to minimize one's exposure to environmental irritants, such as the National Institute of Environmental Health Sciences (which has blogs and podcasts about reducing allergens in one's environment)(NIEHS, 2018) and the Environmental Protection Agency (which provides networks for community-based interventions as well as lists of local and national agencies that are asthma resources) (EPA, 2018), as well as looking into one's state policies regarding asthma.

Asthma is a disease which disproportionally impacts black children and whose effects may still be felt into adulthood. Risk factors for asthma include race/ethnicity, poverty, parental education level, health insurance coverage, environmental (air) quality, living with a smoker, premature birth/ early antibiotic use, Alexithymia, stress, violence, and lack of social support. Through analysis of the PRECEDE-PROCEED model, education and social support were deemed the two most influential factors in asthma related health; therefore, a dual-component intervention was proposed for children and adults. As individuals learn the importance of asthma rates, risks, and symptoms as well as the necessity of family/community support the asthma rates of Black Americans will decrease.

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