In comparison with white parents, the South Asian and “other” ethnic groups, predominantly black African and black Caribbean, more often stated that they did not give preventer medication to their child as prescribed and more frequently expressed the view that most medicines are addictive. The South Asian parents more often than the other two groups expressed the belief that their child would get better from their asthma, and compared with the parents in the white and South Asian groups, those of “other” ethnicity more frequently endorsed the opinion that their child's asthma was out of control. More South Asian parents believed that medicines could do more harm than good. Those of “other” ethnicity expressed concern about the drugs prescribed for their child's asthma.
Parents of “other” ethnicity without post‐secondary education were more reluctant to tell others about their child's asthma. The only indication that the provision of primary care services may be less satisfactory for South Asian parents than for those of white or “other” ethnicity was that they were more satisfied with the service received from hospital than from their GP. It is possible that the GPs involved with the South Asian parents might have been less experienced in the management of childhood asthma than the GPs with whom the white families were registered, leading South Asian parents to have greater confidence in hospital services. All the differences described above showed large effect sizes.
Our findings endorse the underlying model that ethnic groups differ in the social meanings they attribute to asthma. This is demonstrated in our study in relation to beliefs about fate and the interpretation of the nature of asthma. It is also demonstrated in the meaning attributed to prescribed treatments as shown by the differential concerns between ethnic groups expressed about prescribed drugs, about the use of preventer medication, about the belief that medicines may be addictive and about their potential to do more harm than good.
Approximately 20% of the children in our sample had moderate or severe asthma based on parents' reports of the frequency of waking with breathlessness. In the previous year 60% had attended A&E for asthma. Most children in our study were prescribed β‐agonists and corticosteroid inhalers, and almost 40% of the parents reported that their children had been prescribed oral corticosteroids. A recurrent theme in the literature is the persistence of ethnic differences in the rates of attendance at A&E departments for acute asthma episodes regardless of the treatment received and with adjustment for a series of socio‐demographic factors.2,3,5
However, attribution of the difference to socio‐economic factors and less developed approaches to cope with crises have also been documented.16
We aimed to keep the questionnaire short and did not include economic measures, but the large effect size found in our study (2.58) would make it unlikely that an additional socio‐economic question would have explained our results. In most studies the researchers should endeavour to keep the questionnaire short and relevant to the participants.
Adherence to asthma management in some ethnic minority groups has been shown to be poor.17,18,19
Social cognition models state that some individuals in ethnic minority groups have strong beliefs that impact on the interpretation of information and behaviour.19,20,21
From this theoretical framework our findings suggest that parents from ethnic minorities would hold beliefs that may greatly influence the management of their children's asthma. Horne and Weinman found that the difference in scores between necessity and concerns using the Beliefs about Medicines Questionnaire was the strongest predictor of adherence to treatment.19
Parents from non‐white ethnic groups in our study more frequently stated concerns about the safety and addiction potential of asthma drugs in the treatment of chronic conditions in concordance with the findings from a qualitative study.11
This could be the reason why more parents of the two non‐white ethnic groups may have recognised that they did not provide the preventer medication as prescribed and that parents of “other” ethnicity expressed concern about the asthma drugs prescribed. As poor adherence to asthma treatment may be a lost opportunity for health gain and an inefficient use of resources, we would advise, based on our results, that health care providers discuss with parents and older children their concerns in relation to the management of asthma, especially in those from ethnic minorities. Intentional non‐adherence may be high in ethnic minorities in the UK because of their cultural perspectives. Two studies to reduce unscheduled asthma care in multi‐ethnic communities in Britain demonstrated a beneficial effect in the management of asthma, but in both studies there was concern that the effect was less noticeable in those from ethnic minorities.22,23
This would indicate that any educational package should include a cultural perspective that would be relevant to those from ethnic minorities. Such an approach has been tried in a small study involving Afro‐Caribbean and Hispanic groups in the United States. The findings look promising, but the programme is resource intensive as it involves three 1 h sessions.24
Parents of “other” ethnicity were prone to indicate that faith is an important coping mechanism regarding their child's asthma, while those from the South Asian group were confident that their child would get better. In conjunction with their views about asthma management, these beliefs would suggest that parents from ethnic minorities have views about asthma that perceive its outcome as independent of treatment. Our findings were around cultural rather than educational level issues because none of the variables related to management or outcome of asthma were associated with the parental educational level. However, it is possible that other socio‐economic factors might also play a role in influencing parent behaviour concerning the management of their children's asthma. There is much less research on cultural barriers to appropriate care in relation to the subjects' beliefs that by being proactive they could modify the prognosis of a disease.15
Parents from ethnic minorities in our study expressed reliance on destiny, faith and optimism more frequently than white parents. From this perspective our study supports the contention that asthma management could be improved by developing confidence in parents from ethnic minorities that they are able to cope with their children's asthma.25,26
What is already known on this topic
- In Britain South Asian parents and those of black ethnicity use Accident and Emergency services more often than white parents when their children have an asthma attack.
- Parents' health beliefs act as barriers to health care in ethnic minorities.
What this study adds
- South Asian and other ethnic minority groups are reluctant to let others know that their children have asthma.
- Parents of non‐white ethnicity are less willing to give their children with asthma preventer medication on a daily basis and have greater concerns about the unintended effects of the medicines that are prescribed.
A finding of great concern from our study is the reluctance of parents to share issues related to their children's asthma with others. This same reluctance was found to be associated with a lack of post‐secondary educational level. These attitudes are paralleled in studies of Indian mothers who expressed concern and denial when confronted with a diagnostic label of asthma.27
The degree of stigma attached to asthma may be greater among those of lower educational level and may explain the lack of consistency of findings on the prevalence of asthma in South Asian in comparison to other ethnic communities.12,28,29,30,31
Findings of the association between ethnicity and the excess admission to hospital and use of A&E departments are more consistent.1,7,8,9,10
We acknowledge that cultural differences occur among Pakistani and Indian families. In our sample the majority of South Asian participants had a relatively low level of education (the socio‐economic proxy measure) and were therefore likely to comprise less advantaged groups in the population, who retain stronger cultural beliefs. Relating to this, three‐quarters of South Asian respondents were born outside the UK (table 1).
Our study was restricted to a population receiving care from specialised hospital services and A&E departments and therefore does not represent the population with asthma in the community but a subgroup under hospital care. Our study has the advantage of focussing on children with more serious asthma already receiving care. It has the disadvantage that we cannot extrapolate our findings to the general population in which the percentage of severe cases of asthma is usually low, for analysis. It provides a sample of parents well aware of their child's asthma, concerned about the condition and managing the asthma.
In this study, due to the sample size relatively large effect sizes were required in order to identify statistically significant explanatory variables. For some items of the questionnaire, inspection of the p values shows that a number of variables were of marginal statistical significance. However, with many of the items the effect of ethnicity was evident, pointing to consistent findings regarding the importance of ethnic group.
In conclusion, our study has uncovered possible mechanisms that may act as barriers to the management of asthma, especially in South Asian and other ethnic minorities. These barriers are related to beliefs that asthma medicines may be more harmful than beneficial, that the outcome of asthma is more subject to faith and chance than to the usefulness of treatment, and that asthma in children generates unacceptable stigma. Higher rates of admission to hospitals and attendance at A&E of children from ethnic minority groups in comparison to white patients may be reduced by a management strategy that takes into account the differences in beliefs about asthma and its treatment.