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The Challenge of Asthma in Minority Populations

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Abstract

The burden and disparity of asthma in race/ethnic minorities present a significant challenge. In this review, we will evaluate data on asthma epidemiology in minorities, examine potential reasons for asthma disparities, and discuss strategies of intervention and culturally sensitive care.

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Acknowledgments

The authors thank Yvonne Sargent and Suzanne Beattie, MLIS for medical literature research, Lara Akinbami, MD, with assistance for with the CDC NCHS and NHIS data and review of the manuscript, Kathleen Abanilla, MPH for CHIS access assistance, and Diana Carolina Sanchez Mendez for assistance in preparation of figures.

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Correspondence to Albin B. Leong.

Appendix

Appendix

Dyspnea: Description and symptom management in different racial/ethnic groups

  • Afghans: Women may experience dyspnea in a panic or anxiety attack. Persons with dyspnea tend to report it immediately, fearing they are dying. Most can use a numerical scale for dyspnea, but elderly might use words such as “my heart is about to stop” or “I have difficulty breathing.” They want immediate oxygen and medications. As with pain, prayer and listening to the Koran are useful.

  • African-Americans: Descriptors—tight throat, scared–agitated, voice tight, itchy throat, tough breath; “Difficulty catching breath”; acceptance of oxygen and/or opiates to control dyspnea if explained (fear of addiction is strong).

  • American Indians/Alaskan natives: Lungs are associated with freedom, so tightness of breath may be construed as a hindrance. Wide use of oxygen to alleviate symptoms, especially among elders.

  • Arabs: (deekat nafas) Panic accompanies feeling of not being unable to breathe. Tend to hyperventilate. Need careful coaching about meaning of oxygenation, associated with severity and urgency of situation. May be unable to translate dyspnea discomfort into numbers. Prefer medications to control dyspnea, believing they are the best method. Clinician needs to rehearse oxygenation, including timing and length of use.

  • Brazilians: (falta de ar—lack of air) Attributed to both emotional and physical causes. Generally accept oxygen, although its use may suggest increase in gravity of illness.

  • Cambodians (Khymer): (pibak dok dong hoem) Become anxious if cannot breathe. Some Khmer have died from sudden, unexpected nocturnal death syndrome, characterized by an inability to breathe plus cardiac symptoms. They describe dyspnea as no air to breathe or shortness of breath. Will use inhaler and oral medications.

  • Central Americans: (corto de respiracion) Anxious when dyspneic. View the use of oxygen or other “high tech” interventions viewed as sign of increasing gravity of illness. Very commonly apply Vicks VapoRub™ to help improve breathing.

  • Chinese: Too much Yin or a stressful event can cause it. Patients readily accept oxygen. Some patients treat it by eating hot soup/broths and wearing warm clothes.

  • Columbians: Express “being without air” or “unable to breathe” as “quedarse sin aire” or “no poder respirar”. Patient/relatives may be very anxious. Expect and accept oxygen when this occurs; may accept other medications if need for them is explained. Non-pharmacological approaches, such as prayer or relaxation techniques, acceptable.

  • Cubans: (corto de aire, or “short of breath”) May express fear and anxiety by becoming very verbal or crying, by a great show of emotions. Readily accept oxygen. Useful for clinician to suggest non-pharmacological control methods.

  • Dominicans: (falta de respiro) If a person thinks something seriously wrong, he/she will go to physician and accept treatment, including oxygen. Sometimes, family members pour cold water over his/her head. Family may take the person outside for fresh air to see if this improves the breathing problem.

  • East Indians (san ukhrna and swasan muttal [breathlessness]). May become very anxious and frightened, and hyperventilate; consider dyspnea a sign of death. Accept oxygen without hesitation. Some use home remedies such as licorice and ginger tea.

  • Ethiopians and Eritreans: Will hyperventilate and panic. Family members also panic and hover over the sick person. Will use oxygen, but need reassurance as they associate oxygen and other major intervention with grave disease. Clinician should explain necessity of oxygen to family members because their panic increases patient’s anxiety level.

  • Filipinos: (mahirap huminga or hindi makahinga—“hard to breathe” or “cannot breathe) Clinician may need to explain use of numbers to describe level of dyspnea. Patient may be anxious about using oxygen because it implies more serious illness. May be receptive to relaxation techniques to ease symptoms.

  • Germans: (Atemnot) May get anxious. Use of, and response to, non-pharmacological treatments vary.

  • Greeks: (duspnoia) Manage symptoms same way as the dominant culture does. Use words better than numerical scale to describe activity limitations. Likely to accept opiates for dyspnea because they believe that opiates cure it. May use prayer as a non-pharmacological treatment.

  • Haitians: A primary respiratory ailment is oppression. Haitians use this term to describe asthma, but it includes more than that. Also seems to describe a state of anxiety and hyperventilation. Consider oppression (like many respiratory conditions) a “cold” state. Patient says “I am suffocating” (M ap toufe) or “I can’t breathe” (Mwen pa ka respire). Clinician should offer oxygen only when absolutely necessary, as Haitians associate it with serious disease.

  • Hawaiians: (ka’apa ka hanu I ka houpo, or “pant for breath”) Believe that dyspnea or severe shortness of breath may be caused by someone stealing their breath (i.e., their life force or spirit). Patients may not report dyspnea; health care providers should look for respiratory distress. Patients may use words and/or number ratings to express dyspnea. Clinician can offer oxygen after explaining its purpose and the potential outcome. Patients may accept medication if they cannot “catch their breath.” Hawaiians encourage no-pharmacological treatments, such as relaxation, prayer, and meditation.

  • Hmong: (txog txog siav) May describe shortness of breath as “tired” or “difficulty breathing”. Incidence of asthma increasing among adults and children. Patients infected with human lung fluke (paragonimus) or exposed to biological/chemical warfare may have lung disease. Instead of using numerical scale, clinician should ask patient if dyspnea is mild, moderate, or severe.

  • Iranians: (tange-nafas or nafas-tange—“tight breath”) May overtly show signs of anxiety. Readily accept medication and oxygen to control dyspnea and to relieve accompanying fear. Clinician should reassure patient and family that dyspnea can be controlled to a degree. Should also suggest relaxation exercises.

  • Irish: Commonly describe dyspnea as shortness of breath or an uncomfortable awareness of breathing. Traditional home remedies include herbs such as angelica, coltsfoot, horehound, and thyme, all of which are expectorants. The Irish add licorice tincture to tea to dilate the bronchi and break up phlegm.

  • Italians: (manca il respiro, non posso respirare, or manca il fiato) May equate difficulty breathing or need for oxygen with dying. In most cases, readily accept oxygen but may fear artificial means of respiration. Clinician should reassure patient and family, and educate them about the need for, and use of, respiratory treatment.

  • Japanese: (iki-gurushii or iki-ga-dekinai means “cannot breathe”) Will accept oxygen. Less likely to accept or use narcotic medication.

  • Koreans: (soomi-chap-nida means shortness of breath or dyspnea) Frightening for Koreans; perceive shortness of breath or dyspnea as a sign of serious disease. May not welcome oxygen, fearing that they have progressive disease or that their condition is worsening.

  • Mexicans: (Me falta la respiracion means “I lack breath”; No pueda respirar means “I cannot breathe”) May fear being short of breath, interpreting it as a sign of imminent death. Words may be easier than numbers to describe the degree and intensity of dyspnea, but this depends on the patient’s level of education and comprehension. May interpret use of oxygen as a bad sign. May readily accept oxygen and medications to calm or relieve dyspnea if these are explained. Reassurance and emotional support allay fears of suffocation and death.

  • Nigerians: Sometimes families contribute to patient’s hyperventilation and panic by hovering over him/her. Creating calm and providing assurance are key to reducing anxiety. May accept medications.

  • Pakistanis: (sans ukhrna, or breathlessness) May get very anxious and hyperventilate. Accept oxygen if explained. Clinician should explain approach patient calmly. Some Pakistanis may use home remedies, such as ginger and herbal teas. Some patients prefer to keep themselves warm with extra clothing to avoid getting cold, as Pakistanis consider dyspnea to be a “cold” disease. For patient’s comfort, family caregiver usually recites Koran or reads special prayers from it.

  • Polish: (trudno oddychac’, pronounced trud-no o-de-hach) After immigrating, Poles often worked in large industrial settings. Air pollution and respiratory problems common, exacerbated by high incidence of cigarette smoking. Believe that respiratory problems are due to inadequate air or poor ventilation and that breathing fresh air in the sun helps alleviate them. Older patients seek medical help only when other methods do not work. May seek care or express dyspnea only when severe. Accept oxygen and other physician recommended remedies. Treatment in Poland often included visits to spas. For example, at Tezniowy Park in Ciechocinek, built in 1824, windmills pump mineral water into an extensive, elevated system of twigs that release a vapor believed to heal respiratory ailments. Poles also may breathe vapors prepared from steamed herbs, but this practice is less common in USA.

  • Puerto Ricans: (asfixiao, or shortness of breath) Believe that fanning or blowing into a patient provides oxygen or relieves dyspnea. Also believe that tea made from alligator’s tail, snails, or a plant leaf (savila) improves or heals dyspnea-related illnesses such as asthma and congestive heart failure. Some apply hot, wet compress and/or Metholatum™ to reduce dyspnea.

  • (Roma) Gypsies: Prone to excitement and hyperventilation. Usually accept oxygen but generally fear anesthesia, which Roma refer to as “little death”. May mistake oxygen mask for administration of anesthesia.

  • Russians: (odish’ka) (dyspnea) Non-English speakers grasp chest and moan to express dyspnea. Most use words instead of numbers to describe level. Prefer pharmacological methods to relaxation techniques. May get more anxious because of language barrier. Accept oxygen.

  • Samoans: (faigata le manava, pronounced faye-gah-TAH leh mah-NAH-vah, means trouble with breathing; sela, pronounced SAY-lah, means shortness of breath). It is okay to administer oxygen after explaining the procedure. Shortness of breath may cause anxiety. If clinician knows the primary cause of dyspnea, he/she should explain it and the treatment to the patient. Prayer, massage, or presence of intimates may help reduce patient’s anxiety.

  • Vietnamese: (khó tho—means difficulty breathing). Family more likely than patient to report dyspnea. May understand numerical scale but using it might be difficult as patient becomes anxious and begins hyperventilating. Accept oxygen. Reassuring words are helpful.

  • West Indians/Caribbeans: Viewed as serious medical condition, generally associated with asthma. Seek conventional medical help. Accept oxygen and opioids to control dyspnea and, if asked, will express their breathing discomfort, using words to describe discomfort level.

  • (Former) Yugoslavians: (ote˘zano disanje) Consider dyspnea a very serious condition that requires immediate reporting, especially in a child. Describe it, as “I cannot breathe or “I’m going to die”. Seek immediate medical attention on the assumption that it is a heart attack. Accept oxygen and any medication. Need strong assurance that dyspnea can be controlled to a certain degree.

(Adapted from Lipson & Dibble with permission from UCSF Nursing Press)

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Leong, A.B., Ramsey, C.D. & Celedón, J.C. The Challenge of Asthma in Minority Populations. Clinic Rev Allerg Immunol 43, 156–183 (2012). https://doi.org/10.1007/s12016-011-8263-1

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