Socioeconomic status associates with worse asthma morbidity among Black and Latinx adults

Abstract

Background: Asthma disproportionately affects African American/Black (AA/B) and Hispanic/Latinx (H/L) patients and individuals with low socioeconomic status (SES), but the relationship between SES and asthma morbidity within these racial/ethnic groups is inadequately understood.

Objective: To determine the relationship between SES and asthma morbidity among AA/B and H/L adults with moderate to severe asthma using multidomain SES frameworks and mediation analyses.

Methods: We analyzed enrollment data from the PeRson EmPowered Asthma RElief randomized trial, evaluating inhaled corticosteroid supplementation to rescue therapy. We tested for direct and indirect relationships between SES and asthma morbidity using structural equation models. For SES, we used a latent variable defined by poverty, education, and unemployment. For asthma morbidity, we used self-reported asthma exacerbations in the year before enrollment (corticosteroid bursts, emergency room/urgent care visits, or hospitalizations), and Asthma Control Test scores. We tested for mediation via health literacy, perceived stress, and self-reported discrimination. All models adjusted for age, sex, body mass index, ethnicity, and comorbidities.

Results: Among 990 AA/B and H/L adults, low SES (latent variable) was directly associated with hospitalizations (β = 0.24) and worse Asthma Control Test scores (β = 0.20). Stress partially mediated the relationship between SES and increased emergency room/urgent care visits and worse asthma control (β = 0.03 and = 0.05, respectively). Individual SES domains were directly associated with asthma morbidity. Stress mediated indirect associations between low educational attainment and unemployment with worse asthma control (β = 0.05 and = 0.06, respectively).

Conclusions: Lower SES is directly, and indirectly through stress, associated with asthma morbidity among AA/B and H/L adults. Identification of stressors and relevant management strategies may lessen asthma-related morbidity among these populations.

Keywords: Minority populations; asthma exacerbations; discrimination; education; employment; health literacy; income; mediation analysis; severe persistent asthma; stress; structural equation models.

Figure 1 legend.

Conceptual diagram of the Structural Equation Model (SEM) depicting direct and indirect associations between independent (socioeconomic status latent variable or its individual domains) and dependent variables (asthma morbidity measures) and potential mediators (inadequate health literacy, perceived stress, and self-reported discrimination). The variable “C” refers to the total effect of the independent variable on the dependent variable, including direct and indirect effects.

Figure 2 legend.

Structural equation model (SEM) depicting direct and indirect associations between low socioeconomic status (SES) and poor asthma control mediated by high self-perceived stress. Numbers shown indicate pathway beta coefficients within the SEM. Those in red denote significant associations, while those in gray denote insignificant ones. The latent variable labeled “Low SES status” is composed of three SES domains: income- and household size-determined poverty status,^, unemployment, and low educational level attainment. Poor asthma control is indicated by lower Asthma Control Test® scores.

Figure 3 legend.

Structural equation model (SEM) depicting a direct association between low socioeconomic status (SES) and asthma-related hospitalizations. Numbers shown indicate pathway beta coefficients within the SEM. Those in red denote significant associations, while those in gray denote insignificant ones. The latent variable labeled “Low SES status” is composed of three SES domains: income- and household size-determined poverty status,^, unemployment, and low educational level attainment. Hospitalizations are asthma related.

Figure 4 legend.

Structural equation model (SEM) depicting an indirect association between low socioeconomic status (SES) and asthma-related emergency room (ER)/urgent care (UC) visits mediated by high self-perceived stress. Numbers shown indicate pathway beta coefficients within the SEM. Those in red denote significant associations, while those in gray denote insignificant ones. The latent variable labeled “Low SES status” is composed of three SES domains: income- and household size-determined poverty status,^, unemployment, and low educational level attainment. ER/UC visits are asthma related.