Tyra Bryant-Stephens, a doctor who is medical director of the Community Asthma Prevention Program at Children's Hospital of Philadelphia, thinks doctors and researchers need to think more about an often unseen factor in patients' asthma: their housing.
When doctors see poor patients in clinics, she said, they may not have time to ask about their living conditions. Even if they did, patients might be too embarrassed to tell them.
If they went to patients' homes, as community health workers in Bryant-Stephens' program have been doing for 18 years, they might find them full of possible asthma triggers. They also might learn about the stresses that make it hard for their patients to take their medicines properly.
Bryant-Stephens worked with researchers from the University of Pennsylvania to discover what community health workers saw when they visited adult asthma patients in their low-income Philadelphia neighborhoods. Community health workers are lay workers who are trained to help patients with health problems. They are often from the same areas as the patients they serve. A discussion of what they found was published recently in the Journal of Allergy and Clinical Immunology.
"We found that some of the most extreme living conditions make it difficult or impossible for patients to attend medical visits and adhere to optimal asthma care," the team wrote.
"Poor housing is the elephant in the asthma room and must be addressed in a deliberate and intentional manner to truly eliminate disparities in outcomes among adult patients with asthma."
Bryant-Stephens said doctors who work with adult asthma patients would do well to add community health workers to their care teams.
For the study, the health workers made several trips to patients' homes to talk to them about their asthma care plus other issues in their lives, including their reading and math ability, depression, exposure to violence, and social support. The workers reported that many patients were isolated and stressed. Many rented one room or lived in houses crowded with family members. Some cried when the workers asked about depression. Some lived in substandard housing where they were exposed to asthma triggers: mold, rodents, roaches and tobacco smoke. "The houses are full of smoke. Everybody smokes," one of the health workers wrote. People perceived smoking as a stress reliever.
"Without addressing these social stressors," the report said, "clinicians cannot treat the patient even if they can prescribe medications, and the health-care system may be limited in its ability to help these sicker asthmatic people."
Bryant-Stephens said asthma is largely an allergic condition in children but is more complicated in adults. Other illnesses, stress and obesity can increase risk.
She said some of her colleagues were "shocked" by what the community health workers found. Because she has long experience with home visits, her reaction was different. "I wasn't as surprised as dismayed by these conditions," she said.
She thinks doctors should try new ways to find out what keeps patients from having better health. "I think there is a population where we have to think about the fact that we don't get all the information in the office," she said.