|Year : 2014 | Volume
| Issue : 2 | Page : 63-67
Cultural factors impacting asthma management in Asian Indian children
Naveen Mehrotra1, Maya Ramagopal2, Sunita Dodani3
1 Department of Pediatrics, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
2 Department of Pediatrics, Division of Pulmonology and Cystic Fibrosis, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
3 Department of Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA
|Date of Web Publication||15-Sep-2014|
Department of Pediatrics, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
Source of Support: None, Conflict of Interest: None
Introduction: Asthma is the most common chronic disease found in young children. Asian Indians are second largest Asian immigrant population and the fastest growing group in the United States. As this segment of the population in the US grows and utilizes the health care system, more physicians will encounter increased burden of asthma cases. Objective: To outline the cultural factors and health beliefs in the Asian Indian population which impact the care and outcome of these patients. Methods: Three cases are described in which the care of the child with asthma had been impacted due to cultural factors or limitations resulting from health beliefs. The common cultural factors researched in the reported literature along with the experiences of various physicians are outlined. Result: Reported beliefs include concern and denial in Asian Indian mothers when given a diagnosis of asthma in their child. Due to the fear of use of preventive medications such as inhaled corticosteroids and not being completely confident in the medical system, they may not feel comfortable with the recommendations that are made for control of their asthma. Conclusion: Enhanced knowledge with empowerment of the provider will improve communication and compliance of the patient and an improved collaboration between the patient and health care provider leading to better health outcomes in Asian Indian patients with asthma.
Keywords: Asian Indian, asthma management, children, cultural factors, health beliefs
|How to cite this article:|
Mehrotra N, Ramagopal M, Dodani S. Cultural factors impacting asthma management in Asian Indian children. Indian J Allergy Asthma Immunol 2014;28:63-7
|How to cite this URL:|
Mehrotra N, Ramagopal M, Dodani S. Cultural factors impacting asthma management in Asian Indian children. Indian J Allergy Asthma Immunol [serial online] 2014 [cited 2017 Apr 23];28:63-7. Available from: http://www.ijaai.in/text.asp?2014/28/2/63/140761
| Introduction|| |
Asthma is the most common chronic disease found in children. The international literature reports that hospitalization and mortality rates from asthma are high. Financial burden of expensive asthma medications has been associated with treatment noncompliance and increased rates of asthma hospitalization among the general US children aged 5 years or younger.  To improve outcomes in the management of asthma in children, currently four major sets of guidelines have been created by various governing organizations,  including the expert panel report 3 of the National Asthma Education Program,  the practicing allergology consensus report published by the European Academy of Asthma and Allergy in 2008,  an evidence-based approach compiled by the European Respiratory Society Task Force, published in the European Respiratory Journal in 2008  and most recently the evidence-based guidelines for the diagnosis and management of asthma in children 5 years and younger published by the Global Initiative for Asthma. 
Asian Indians are one such ethnic minority group and the fastest growing immigrant populations in the United States. , The Asian Indian population is considerably heterogeneous in languages and religions, but shows cultural similarity, especially in reported attitude to the health-related aspects of life.  In this paper, we outline one such set of cultural beliefs that may impact the management of asthma in Asian Indian children.
Health disparities have been highlighted in the institute of medicine's report on health outcomes in different ethnic minorities.  This variance in outcomes can be affected by many different factors, which may not be changeable. Understanding of the cultural concepts and beliefs can help the health care provider to better manage the care and improve compliance and effectiveness of the treatments in various cultural groups.  Cross-cultural care requires that clinicians be open minded and seek to understand the various dynamics of the patient-clinician encounter, such as variations in the perception of illness, diverse belief systems around health, differences in help-seeking behaviors, and preferences in approaches to health care. This care is not a question of "doing the right thing;" rather, an important vehicle for achieving patient satisfaction, patient safety, and improved health outcomes. The major guidelines do not address the cultural nuances that may impact compliance to enhance and improve management outcomes.
The objective of this paper is to describe case reports highlighting cultural beliefs among Asian Indian families that have impacted the care of children in the treatment of their asthma. The pulmonary clinics have seen a steady rise in the Asian Indian patient population in the last few years. The following three cases were selected as they occurred over the span of 1 year and were difficult to manage. The families were of high socioeconomic status and well-educated with at least one parent with a college degree. The case study was classified as exempt by the Institutional Review Board at Saint Peters University Hospital in New Brunswick, New Jersey for compilation and distribution for educational purposes.
| Case reports|| |
Case 1: The burning incense, an environmental allergen
A 6-year-old Asian Indian boy presented to the pulmonary clinic with his mother with a history of recurrent cough and wheeze for the past 2 years, which was being managed by their pediatrician. He was diagnosed with mild persistent asthma and had been started on daily inhaled corticosteroid. At a follow-up visit in 2 months, his symptoms had worsened and the dose of the corticosteroid was increased. At that time the child had been enrolled in an ongoing clinical study to evaluate the effects of the home environment and the development of asthma. During a home visit required by the research protocol, the research team noted that that there were a significant number of incense candles and sticks burning in the living room, a place where the child spent most of his time. At a subsequent clinic visit, it was suggested to the mother that the incense burning may be the primary cause for the poor control of the asthma. The mother responded in agreement that she was aware that this could be the problem. However, since it was her mother-in-law's practice and something she could not oppose due to her cultural upbringing, she was expected to comply.
Case 2: Fear of medications: Treatment and chronic management of asthma
A 10-year-old Asian Indian female seen in consultation by the pulmonologist during her admission to the pediatric intensive care unit for an asthma exacerbation. During the admission, she developed a pneumothorax that required a chest tube. She has previously been diagnosed with asthma and inhaled steroids had been recommended. The family had not been compliant with the recommendations. At follow-up visits to pulmonary clinic, it was noted that her pulmonary function tests continued to show moderate obstruction, which did not change despite reports of compliance of medications. A few months later, the family requested a letter for her exclusion from school gym activities. Since this was not the recommendation for the management of asthma, the parents were questioned further about their request. The family reported that the child was getting symptomatic in gym where she was unable to run and would become short of breath. After much questioning, the parents admitted that the child had not been given the steroid based medication as they were very concerned about taking inhaled steroids long-term. "Steroids are known to stop growth and destroy the bones."
Case 3: Diet restrictions and the use of alternative forms of treatment
A 4-year-old child presented to the primary care physician with a history of repeated episodes of cough and cold, which had been treated with over the counter allergy medications and occasional nebulizer treatments. The parents stated that the cold symptoms would start when the child went outdoors in the cold and when he ate ice cream. He had eczema that was being incompletely managed with topical lotions and prescribed steroid creams. Due to the recurrence in the symptoms and the lack of complete resolution, the parents had discussed the problem with their relative in India, who was a homeopathic practitioner, prescribed a treatment regimen for 6 months, without concomitant medications. Another relative who was an ayurvedic practitioner advised the parent to follow strict dietary recommendations. Child was advised not to eat bananas or drink milk whenever he had the cold symptoms as "it would create phlegm and aggravate the cough."
| Discussion|| |
These three cases highlight the different cultural practices and beliefs and influence of the extended family that is prevalent in the South Asian population living in the US. The WHO reports that over 80% of asthma deaths occur in low and lower-middle income countries.  Rates of death in Indians in the United States are largely unknown. Historically, India has had a much lower incidence of asthma as opposed to other developed countries in the world. However, asthma deaths are one of the leading causes of morbidity and mortality in rural India.  Rates of asthma in Asian Indian children in the United States have been reported to be low at 4.4%. 
Asian Indians are one of the fastest growing immigrant populations in the United States. , The Asian Indian population is considerably heterogeneous in languages and religions, but shows cultural similarity, especially in reported attitude to the health-related aspects of life.  It has been shown that Asian Indians are usually found to be well-educated and economically advantaged as compared with other foreign-born US groups.  Asian Indians accept and practice westernized medicine, but have spiritual and religious belief about the complexity of the relationship between health and illness. ,
Asian Indian mothers express concern and denial when given a diagnosis of asthma in their child. , The acceptance of the diagnosis of asthma results in the acknowledgement by the parent that their child carries a chronic illness resulting in an "imperfect "child. This high achieving community parent then has to accept the fact that their child might not be perfect creating a feeling of failure. Asian Indians were twice as less likely to report the diagnosis about their child's asthma than "other" ethnic groups  in speculation as a guilt or shame of having this imperfect child.
Since the respiratory symptoms of asthma have usually been portrayed as life-threatening which often take the life of the person with the disease, a barrier in the acceptance of the diagnosis and the treatment of this disease is inherently prevalent. Asthma is usually seen as a serious disease, which leads to death, a belief propagated by the Bollywood cultural movies and stories in which the Asian Indians are used to seeing the major actors clutching their chests, while looking for their asthma inhalers and succumbing to their illness. As such, parents tend to shy away from hearing about this disease and often deny that their child may have asthma. The majority of Asian Indians believe that asthma and the allergy-related diseases are a problem of their newly adopted country.
Exposure to typical environmental allergens such as pets, pollen and grass are well-known to lead to symptoms of runny nose, cough, sneezing, and wheezing.  However, uncommon triggers such as incense in our case are not routinely identified as causes for repeated episodes of the asthma symptoms. Environmental factors such as ingredients in a typical Indian diet are known to trigger respiratory symptoms of asthma and nasal congestion of allergic rhinitis.  Even if treatment is managed, the ongoing exposure to the allergen does not allow the complete resolution of these symptoms. 
The use of complementary medicine in the treatment of asthma has been reported by all ethnic groups.  Asian Indians are known to use homeopathy and or Ayurveda for the treatment of these chronic illnesses as they are generally believed to be less "harmful in the long-term.  These treatment modalities may sometimes be even offered through the phone and internet by their family members and friends from India without necessarily examining the child. Use of spiritual healers and evaluation of horoscopes are common practices in these situations as they create a ray of hope for these chronically ill patients. Oral and topical ayurvedic, homeopathic, or herbal supplements are given to the child whence received from their home country without the knowledge of the allopathic treating physician in this country. These alternative treatments and lifestyle changes, which are believed, sometimes incorrectly to be more effective and supposedly a lower side-effect profile may become first line treatments of these patients by many families over allopathic medicine. 
Spiritual healers may be used to do special prayers and create special magical concoctions, which are given to the child for their well-being and treatment of the chronic illness. Belief in horoscopes and their effects are well-accepted factors that can influence the child's health. Horoscopes are evaluated by specialists to determine the chronicity of the illness and for prediction of improvements in those conditions. Special amulets, stone therapies, and prayers are suggested to make the child better when the child is ill. Instructions are given to the parents to do the prayers or ornamentation of the child with these stones or amulets at special times of the day or night. Special articles of religious significance are given to the child to wear. Removal of these articles even if required by medical professionals is considered inauspicious to the point where it may aggravate the symptoms of the disease and distance the provider from the family of the illness.
Their strong belief in the theories of Ayurveda, the inherent fundamental component of healthy living, which has been taught to the Asian Indians since birth dictates the importance of maintaining a balance among the three humors of life, bile, wind, and phlegm.  Imbalances in the body of these create illnesses such as these allergy related disorder. In order to regain balances changes in the daily lifestyle and food intakes are mandated for the child. Allergies are considered to have an underlying imbalance, which requires avoidance of all foods that has a "cold" base such as rice, yogurt, juice, etc.  Restrictions in such foods are a common theme in the treatment of allergies along with various other illnesses. Teas and milk with ginger, honey, black pepper, and turmeric, remedies considered to have a "hot" base per the ayurvedic recommendations, are compounded and given to the child to get rid of these symptoms. The parent might also try to create more heat in the child by overdressing to help alleviate the hot-cold imbalance.
Studies from the United Kingdom report a much higher incidence of Emergency Room visits and hospitalizations from asthma in South Asian children of which Asian Indians are the largest subgroup. A survey of parents of 150 South Asian children aged 3-9 years with asthma in three different London hospitals serving a high percentage of South Asian patients reflected that South Asian parents were much less compliant with the recommended preventive treatment than were white parents. Most felt that preventive drugs were considered "addictive" and had more side-effects, which would result in more harm than good.  South Asian patients hospitalized for asthma coped differently than white patients.  Due to the fear of use of preventive medications such as systemic corticosteroids and less confidence in their physician, South Asians did not feel comfortable with the recommendations that were made for control of their asthma. Long term prevention and control strategies with maintenance medications may not be easily accepted and administered by the parent. The use of steroids during acute exacerbations and for prevention management meets a lot of resistance due to the fear that the steroids will stunt the growth of the child, a common belief held by many parents. 
Recommendations for provider interaction with parents
Current guidelines for the diagnosis and management of asthma in the NHLBI NAEPP expert panel report include prevention of chronic and troublesome symptoms, aim to decrease frequent use (≤2 days a week) of inhaled short acting beta-agonists for quick relief of symptoms, maintain (near)"normal" pulmonary function and activity levels and meet patients' and families' expectations of and satisfaction with asthma care.  Efforts directed toward instituting more culturally relevant health care enrich the physician-patient relationship and improve patient rapport, adherence, and outcomes. 
With the lessons learned from these cases, we outline the following recommendations for optimal asthma care in the Asian Indian population.
- Be empathetic and try to understand the cultural differences and beliefs of the patient. To improve compliance with treatment and enhance outcomes, a happy medium needs to be created in which the provider can hope for management of the chronic illness to benefit the child in the long run. Cultural beliefs about the disease and the concerns about side-effects can impact the compliance with treatment
- Ensure language access. Even though, the Asian Indian community is considered affluent with the majority being highly educated, over a third of all Asian Indians and more than a half of all Asian Indian seniors do not consider themselves proficient in English,  which may result in limited health literacy and poor treatment compliance
- Involve the elders and family in the discussion of the management of the illness where possible: Due to the family structure and the reverence of elders in the Asian Indian families, family involvement should not only be recognized but expected.  Management of the illness has to be done in cooperation with the family elders as they are considered central in the Asian Indian culture and may often dictate the medical management of the patient
- Discuss the use of alternative or complementary therapies: With a strong family culture, elders, family members, and friends will offer advice toward the treatment of the illness, which may include the use of alternative or complementary therapies which often can be the first line of treatment. , It is appropriate to ask the parents if they are utilizing any of these interventions to alleviate the symptoms of their ailments as this may impact their management
- Incorporate discussion about diet and medications to optimize treatment compliance. Dietary and lifestyle advice would need to be offered as they are part of daily living and an integral component of health and disease management and a common concern for most Asian Indian patients. Beliefs about diet and misinformation about the medication side-effects can impact compliance with treatment
- Understand and investigate trigger factors. Ask about the use of incense or other exogenous environmental irritants that could be a trigger factor for the asthma, especially for children with chronic or persistent asthma symptoms.
| Conclusion|| |
In this paper, we highlighted some of the key cultural concepts about asthma and allergies in Asian Indian children. As this segment of the population in the US grows and utilizes the health care system, more physicians will encounter this group of patients. We concur with Gupta's statement that "Asian Indians are a very heterogeneous group and their healthcare beliefs and practices vary depending upon their education, profession, occupation, socioeconomic status, whether they grew up in cosmopolitan cities or rural areas of India and stage of acculturation and assimilation."  Empowerment of the provider through enhanced knowledge will improve communication and compliance of the patient. We believe that a better understanding and sensitivity to the health beliefs will be instrumental in an improved collaboration between the patient and health care provider and lead to better health outcomes.
| References|| |
|1.||Karaca-Mandic P, Jena AB, Joyce GF, Goldman DP. Out-of-pocket medication costs and use of medications and health care services among children with asthma. JAMA 2012;307:1284-91. |
|2.||Potter PC. Current guidelines for the management of asthma in young children. Allergy Asthma Immunol Res 2010;2:1-13. |
|3.||NIH. National Asthma Education and Prevention Program. Expert Panel Report III: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; National Heart, Lung, and Blood Institute; 2007. NIH Publication No. 07-4051. |
|4.||Bacharier LB, Boner A, Carlsen KH, Eigenmann PA, Frischer T, Götz M, et al. Diagnosis and treatment of asthma in childhood: A PRACTALL consensus report. Allergy 2008;63:5-34. |
|5.||Brand PL, Baraldi E, Bisgaard H, Boner AL, Castro-Rodriguez JA, Custovic A, et al. Definition, assessment and treatment of wheezing disorders in preschool children: An evidence-based approach. Eur Respir J 2008;32:1096-110. |
|6.||Global Initiative for Asthma: Global strategy for the diagnosis and management of asthma in children 5 years and younger, 2009. Available from: http://www.ginasthma.org.[Last accessed on-2013 Dec 04]. |
|7.||Mehrotra N, Gaur S, Petrova A. Health care practices of the foreign born Asian Indians in the United States. A community based survey. J Community Health 2012;37:328-34. |
|8.||Immigration and naturalization service population statistics, 2000. Available from: http://www.ins.usdoj.gov/graphics/aboutins/statistics/299.htm. [Last accessed on-2013 Dec 04]. |
|9.||Ahmed SM, Lemkau JP. Cultural issues in the primary care of South Asians. J Immigr Health 2000;2:89-96. |
|10.||Institute of Medicine Guidance for the national Health Care Disparities Report. 2002. Available from: http://www.iom.edu/Reports/2002/guidance-for-the-National Health care-disparities-Report-aspx. [Last accessed on-2013 Dec 04]. |
|11.||Ashton CM, Haidet P, Paterniti DA, Collins TC, Gordon HS, O′Malley K, et al. Racial and ethnic disparities in the use of health services: Bias, preferences, or poor communication? J Gen Intern Med 2003;18:146-52. |
|12.||Braman SS. The global burden of asthma. Chest 2006;130 1 Suppl: 4S-12. |
|13.||Smith KR. National burden of disease in India from indoor air pollution. Proc Natl Acad Sci U S A 2000;97:13286-93. |
|14.||Brim SN, Rudd RA, Funk RH, Callahan DB. Asthma prevalence among US children in underrepresented minority populations: American Indian/Alaska Native, Chinese, Filipino, and Asian Indian. Pediatrics 2008;122:e217-22. |
|15.||Misra R, Patel TG, Davies D, Russo T. Health promotion behaviors of Gujurati Asian Indian immigrants in the United States. J Immigr Health 2000;2:223-30. |
|16.||Alagiakrishnan K, Chopra A. Health and Health Care of Asian Indian American Elders; 2007. |
|17.||Downes N. Ethnic Americans for the Health Professional. South Asians: Asian Indians. Downes- Dubuque, IA: Kendall/Hunt; 1994. p. 133-8. |
|18.||Lal A, Kumar L, Malhotra S. Knowledge of asthma among parents of asthmatic children. Indian Pediatr 1995;32:649-55. |
|19.||Partridge MR. In what way may race, ethnicity or culture influence asthma outcomes? Thorax 2000;55:175-6. |
|20.||Smeeton NC, Rona RJ, Gregory J, White P, Morgan M. Parental attitudes towards the management of asthma in ethnic minorities. Arch Dis Child 2007;92:1082-7. |
|21.||Cookson W, Moffatt M, Strachan DP. Genetic risks and childhood-onset asthma. J Allergy Clin Immunol 2011;128:266-70. |
|22.||Jain P, Kant S, Mishra R. Perception of dietary food items as food allergens in asthmatic individuals in north Indian population. J Am Coll Nutr 2011;30:274-83. |
|23.||Halken S. Prevention of allergic disease in childhood: Clinical and epidemiological aspects of primary and secondary allergy prevention. Pediatr Allergy Immunol 2004;15 Suppl 16:4-5, 9-32. |
|24.||Knoeller GE, Mazurek JM, Moorman JE. Complementary and alternative medicine use among adults with work-related and non-work-related asthma. J Asthma 2012;49:107-13. |
|25.||Ramakrishna J, Weiss MG. Health, illness, and immigration. East Indians in the United States. West J Med 1992;157:265-70. |
|26.||Pilkington K, Boshnakova A. Complementary medicine and safety: A systematic investigation of design and reporting of systematic reviews. Complement Ther Med 2012;20:73-82. |
|27.||Svoboda RE. Ayurveda′s role in preventing disease. Indian J Med Sci 1998;52:70-7. |
|28.||Hankey A. Ayurvedic physiology and etiology: Ayurvedo Amritanaam. The doshas and their functioning in terms of contemporary biology and physical chemistry. J Altern Complement Med 2001;7:567-74. |
|29.||Griffiths C, Kaur G, Gantley M, Feder G, Hillier S, Goddard J, et al. Influences on hospital admission for asthma in south Asian and white adults: Qualitative interview study. BMJ 2001;323:962-6. |
|30.||Hon KL, Kam WY, Leung TF, Lam MC, Wong KY, Lee KC, et al. Steroid fears in children with eczema. Acta Paediatr 2006;95:1451-5. |
|31.||NNEPR. Guidelines for the Diagnosis and Management of Asthma (EPR-3). http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. [Last accessed 2014 Jun 30]; 2007. |
|32.||Juckett G. Cross-cultural medicine. Am Fam Physician 2005;72:2267-74. |
|33.||Available from: http://www.saalt.org/attachments/1/Demographics%20of%20SA%20NJ%20Community.SAALT%20NJ%20Briefs.pdf. [Last accessed on-2013 Dec 04]. |
|34.||Gupta VB. Impact of culture on healthcare seeking behavior of Asian Indians. J Cult Divers 2010;17:13-9. |