Structural racism and its pathways to asthma and atopic dermatitis
Authors: Adali Martinez, Rosemarie de la Rosa, Mahasin Mujahid, Neeta Thakur
Journal: Journal of Allergy and Clinical Immunology (2021)

Black, Latinx, and Indigenous people in the United States experience a disproportionate burden of asthma and atopic dermatitis. The study of these disease disparities has focused on proximal socioenvironmental exposures and on the biomechanistic (including genetic) differences between racial and ethnic groups. Although biomedical research in allergy and immunology stands to benefit from the inclusion of diverse study populations, the narrow focus on biologic mechanisms disregards the complexity of interactions across biologic and structural factors, including the effects of structural racism. Structural racism is the totality of ways in which society fosters discrimination by creating and reinforcing inequitable systems through intentional policies and practices sanctioned by government and institutions. It is embedded across multiple levels, including the economic, educational, health care, and judicial systems, which are manifested in inequity in the physical and social environment. In this review, we present a conceptual framework and pull from the literature to demonstrate how structural racism is a root cause of atopic disease disparities by way of residential segregation, socioeconomic position, and mass incarceration, which may lead to aberrations in the innate and adaptive immune response and the augmentation of physiologic stress responses, contributing to a disproportionate disease burden for racial and ethnic populations. Black, Latinx, and Indigenous people in the United States experience a disproportionate burden of asthma and atopic dermatitis. The study of these disease disparities has focused on proximal socioenvironmental exposures and on the biomechanistic (including genetic) differences between racial and ethnic groups. Although biomedical research in allergy and immunology stands to benefit from the inclusion of diverse study populations, the narrow focus on biologic mechanisms disregards the complexity of interactions across biologic and structural factors, including the effects of structural racism. Structural racism is the totality of ways in which society fosters discrimination by creating and reinforcing inequitable systems through intentional policies and practices sanctioned by government and institutions. It is embedded across multiple levels, including the economic, educational, health care, and judicial systems, which are manifested in inequity in the physical and social environment. In this review, we present a conceptual framework and pull from the literature to demonstrate how structural racism is a root cause of atopic disease disparities by way of residential segregation, socioeconomic position, and mass incarceration, which may lead to aberrations in the innate and adaptive immune response and the augmentation of physiologic stress responses, contributing to a disproportionate disease burden for racial and ethnic populations. Racial and ethnic health disparities have persisted, and in the case of atopic diseases, they have worsened1Odlum M. Moise N. Kronish I.M. Broadwell P. Alcántara C. Davis N.J. et al.Trends in poor health indicators among Black and Hispanic middle-aged and older adults in the United States, 1999-2018.JAMA Netw Open. 2020; 3: 1-14Crossref Scopus (5) Google Scholar despite scientific research dedicated to untangling the contributing biomechanisms and dedicated efforts to address poorly controlled disease,2Eichenfield L. Tom W. Chamlin S. Feldman S. Hanifin J. Simpson E. et al.Guidelines of care for the management of atopic dermatitis.J Am Acad Dermatol. 2014; 70: 338-351Abstract Full Text Full Text PDF PubMed Scopus (509) Google Scholar, 3Wechsler M.E. Szefler S.J. Ortega V.E. Pongracic J.A. Chinchilli V. Lima J.J. et al.Step-up therapy in Black children and adults with poorly controlled asthma.N Engl J Med. 2019; 381: 1227-1239Crossref PubMed Scopus (24) Google Scholar, 4National Asthma Education and Prevention ProgramExpert panel report 3: guidelines for the diagnosis and management of asthma. National Heart Lung and Blood Institute, Bethesda, Md2007Google Scholar including the rampant introduction of precision medicine therapy.5Ray A. Camiolo M. Fitzpatrick A. Gauthier M. Wenzel S.E. Are we meeting the promise of endotypes and precision medicine in asthma?.Physiol Rev. 2020; 100: 983-1017Crossref PubMed Scopus (17) Google Scholar,6Balakirski G. Novak N. Novel therapies and the potential for a personalized approach to atopic dermatitis.Curr Opin Allergy Clin Immunol. 2021; 21: 368-377PubMed Google Scholar Asthma and atopic dermatitis are 2 of the most common chronic conditions of childhood in the United States, often persisting into adulthood.7National asthma data. US Centers for Disease Control and Prevention, Atlanta, Ga2019https://www.cdc.gov/asthma/most_recent_national_asthma_data.htmDate accessed: July 7, 2021Google Scholar,8Chiesa Fuxench Z.C. Block J.K. Boguniewicz M. Boyle J. Fonacier L. Gelfand J.M. et al.Atopic Dermatitis in America Study: a cross-sectional study examining the prevalence and disease burden of atopic dermatitis in the US adult population.J Invest Dermatol. 2019; 139: 583-590Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Asthma affects more than 5.1 million children and more than 20 million adults, corresponding to 7.8% of the US population.7National asthma data. US Centers for Disease Control and Prevention, Atlanta, Ga2019https://www.cdc.gov/asthma/most_recent_national_asthma_data.htmDate accessed: July 7, 2021Google Scholar Approximately 7.3% of adults and 13% to 15% of children have atopic dermatitis.8Chiesa Fuxench Z.C. Block J.K. Boguniewicz M. Boyle J. Fonacier L. Gelfand J.M. et al.Atopic Dermatitis in America Study: a cross-sectional study examining the prevalence and disease burden of atopic dermatitis in the US adult population.J Invest Dermatol. 2019; 139: 583-590Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar, 9Silverberg J.I. Simpson E.L. Associations of childhood eczema severity: a US population-based study.Dermatitis. 2014; 25: 107-114Crossref PubMed Scopus (127) Google Scholar, 10McKenzie C. Silverberg J.I. The prevalence and persistence of atopic dermatitis in urban United States children.Ann Allergy Asthma Immunol. 2019; 123: 173-178.e1Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar As is the case with many chronic health conditions, the burden of atopic diseases disproportionally affects Black and Brown communities.11Zahran H.S. Bailey C.M. Damon S.A. Garbe P.L. Breysse P.N. Vital Signs: asthma in children — United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 149-155Crossref PubMed Google Scholar, 12Keet C.A. Matsui E.C. McCormack M.C. Peng R.D. Urban residence, neighborhood poverty, race/ethnicity, and asthma morbidity among children on Medicaid.J Allergy Clin Immunol. 2017; 140: 822-827Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 13Lowe A.A. Bender B. Liu A.H. Solomon T. Kobernick A. Morgan W. et al.Environmental concerns for children with asthma on the Navajo Nation.Ann Am Thorac Soc. 2018; 15: 745-753Crossref PubMed Scopus (10) Google Scholar, 14Washington D.M. Curtis L.M. Waite K. Wolf M.S.P.-O.M. Sociodemographic factors mediate race and ethnicity-associated childhood asthma health disparities: a longitudinal analysis.J Racial Ethn Health Disparities. 2018; 5: 928-938Crossref PubMed Scopus (11) Google Scholar, 15Brunner P.M. Guttman-Yassky E. Racial differences in atopic dermatitis.Ann Allergy Asthma Immunol. 2019; 122: 449-455Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 16Kim Y. Blomberg M. Rifas-Shiman S.L. Camargo C.A. Gold D.R. Thyssen J.P. et al.Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis.J Invest Dermatol. 2019; 139: 827-834Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 17Wegienka G. Havstad S. Joseph C.L.M. Zoratti E. Ownby D. Woodcroft K. et al.Racial disparities in allergic outcomes in African Americans emerge as early as age 2 years.Clin Exp Allergy. 2012; 42: 909-917Crossref PubMed Scopus (44) Google Scholar The persistence of disparities requires a shift of the biomedical framework to incorporate root causes, particularly the direct and indirect roles of structural racism.18Stempel H. Federico M.J. Szefler S.J. Applying a biopsychosocial model to inner city asthma: recent approaches to address pediatric asthma health disparities.Paediatr Respir Rev. 2019; 32: 10-15PubMed Google Scholar Structural racism is both historically rooted and culturally reinforced.19Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (950) Google Scholar It is the totality of ways in which society fosters discrimination by creating and reinforcing inequitable systems through intentional policies and practices sanctioned by various levels of government and institutions.19Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (950) Google Scholar, 20Williams D.R. Lawrence J.A. Davis B.A. Racism and health: evidence and needed research.Annu Rev Public Health. 2019; 40: 105-125Crossref PubMed Scopus (374) Google Scholar, 21Bailey Z.D. Feldman J.M. Bassett M.T. How structural racism works — racist policies as a root cause of U.S. racial health inequities.N Engl J Med. 2021; 384: 768-773Crossref PubMed Scopus (0) Google Scholar Structural racism is embedded across society, including in our economic, educational, health care, and justice systems, manifesting as inequitable distribution of resources.19Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (950) Google Scholar This is distinct from interpersonal racism, which is the differential treatment with regard to race, skin color, ethnic origin, or immigration status.22Thakur N. Barcelo N.E. Borrell L.N. Singh S. Eng C. Davis A. et al.Perceived discrimination associated with asthma and related outcomes in minority youth: the GALA II and SAGE II studies.Chest. 2017; 151: 804-812Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Although we have focused this review on the role of structural racism contributing to the disparities within the Black, Latinx, and Indigenous communities,11Zahran H.S. Bailey C.M. Damon S.A. Garbe P.L. Breysse P.N. Vital Signs: asthma in children — United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 149-155Crossref PubMed Google Scholar, 12Keet C.A. Matsui E.C. McCormack M.C. Peng R.D. Urban residence, neighborhood poverty, race/ethnicity, and asthma morbidity among children on Medicaid.J Allergy Clin Immunol. 2017; 140: 822-827Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 13Lowe A.A. Bender B. Liu A.H. Solomon T. Kobernick A. Morgan W. et al.Environmental concerns for children with asthma on the Navajo Nation.Ann Am Thorac Soc. 2018; 15: 745-753Crossref PubMed Scopus (10) Google Scholar, 14Washington D.M. Curtis L.M. Waite K. Wolf M.S.P.-O.M. Sociodemographic factors mediate race and ethnicity-associated childhood asthma health disparities: a longitudinal analysis.J Racial Ethn Health Disparities. 2018; 5: 928-938Crossref PubMed Scopus (11) Google Scholar,16Kim Y. Blomberg M. Rifas-Shiman S.L. Camargo C.A. Gold D.R. Thyssen J.P. et al.Racial/ethnic differences in incidence and persistence of childhood atopic dermatitis.J Invest Dermatol. 2019; 139: 827-834Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,23Asthma and American Indians/Alaska Natives. Office of Minority Health, US.Department of Heath and Human Services, Washington, DC2021https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=30Google Scholar, 24Hanifin J.M. Reed M.L. Group EP and IWA population-based survey of eczema prevalence in the United States.Dermatitis. 2007; 18: 82-91Crossref PubMed Scopus (237) Google Scholar, 25Brewer M. Kimbro R.T. Denney J.T. Osiecki K.M. Moffett B. Lopez K. Does neighborhood social and environmental context impact race/ethnic disparities in childhood asthma?.Health Place. 2017; 44: 86-93Crossref PubMed Scopus (22) Google Scholar we recognize that the pervasive effects of structural racism have likely influenced disease outcomes in many—if not all—minoritized communities in the United States. For this review, we use the term Latinx. Although this term has not been fully adopted by all of the population, given the topic of this review, we believed it important to select a term that represents a global movement toward more gender-inclusive terms.26Salinas C. Lozano A. Mapping and recontextualizing the evolution of the term Latinx: an environmental scanning in higher education.J Latinos Educ. 2019; 18: 302-315Crossref Scopus (99) Google Scholar We also recognize that Latinx encompass diverse subgroups with unique migration to the United States; however, these groups also share cultural and environmental risk factors for atopic diseases that are influenced by structural and societal factors.27Mcquaid E.L. Koinis-Mitchell D. Canino G.J. Acculturation.in: Celedón J.C. Achieving respiratory health equality. respiratory medicine. Humana Press, Totowa, NJ2017Crossref Google Scholar Indigenous populations refer to descendants of the peoples who inhabited the Americas before European colonization. A deeper understanding of the history and the ongoing oppression of Black, Latinx, and Indigenous populations in the United States is needed to understand the deep-rooted and broad effect of structural racism on health outcomes, and specifically, on asthma and atopic dermatitis. This review examines the direct and indirect pathways by which structural racism may increase disease and worsen morbidity for asthma and atopic dermatitis. In the sections that follow, we provide a conceptual framework of structural racism and mechanisms of how it has been manifested in the United States, review the racial and ethnic disparities for asthma and atopic dermatitis, summarize the literature examining pathways of structural racism, and conclude with recommendations for future research and efforts that move toward reducing disease disparities. Racial categories in the United States were originally established by European settlers to assert power over enslaved African and Indigenous people, who were falsely thought to be innately, intellectually, and morally inferior.19Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (950) Google Scholar Over centuries, the concept of race and racial differences has been propagated by the field of medicine with the use of racial taxonomies in research and clinical practice.28Witzig R. The medicalization of race: scientific legitimization of a flawed social construct.Ann Intern Med. 1996; 125: 675-679Crossref PubMed Google Scholar To understand how structural racism contributes to disparities in asthma and atopic dermatitis, we propose the following conceptual framework (Fig 1) pulling from the work of Williams and Mohammed,29Williams D.R. Mohammed S.A. Racism and health I: pathways and scientific evidence.Am Behav Sci. 2013; 57: 1152-1173Crossref Scopus (452) Google Scholar Williams et al,30Williams D.R. Lawrence J.A. Davis B.A. Vu C. Understanding how discrimination can affect health.Health Serv Res. 2019; 54: 1374-1388Crossref PubMed Scopus (83) Google Scholar Bailey et al,19Bailey Z.D. Krieger N. Agénor M. Graves J. Linos N. Bassett M.T. Structural racism and health inequities in the USA: evidence and interventions.Lancet. 2017; 389: 1453-1463Abstract Full Text Full Text PDF PubMed Scopus (950) Google Scholar Bailey et al,21Bailey Z.D. Feldman J.M. Bassett M.T. How structural racism works — racist policies as a root cause of U.S. racial health inequities.N Engl J Med. 2021; 384: 768-773Crossref PubMed Scopus (0) Google Scholar and the World Health Organization's Commission on Social Determinants of Health framework.31A conceptual framework for action on the social determinants of health. Social determinants of health discussion paper 2 (policy and practice). World Health Organization, Geneva, Switzerland2010http://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdfGoogle Scholar The determinants of health include biology, geographic origin and ancestry, health behavior, and the socioenvironmental context as influenced by societal institutions and structural racism (Fig 1).29Williams D.R. Mohammed S.A. Racism and health I: pathways and scientific evidence.Am Behav Sci. 2013; 57: 1152-1173Crossref Scopus (452) Google Scholar,31A conceptual framework for action on the social determinants of health. Social determinants of health discussion paper 2 (policy and practice). World Health Organization, Geneva, Switzerland2010http://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdfGoogle Scholar These determinants of health interact, and as is the case with health behaviors, they may be influenced heavily by socioenvironmental conditions.32Cohen D.A. Scribner R.A. Farley T.A. A structural model of health behavior: a pragmatic approach to explain and influence health behaviors at the population level.Prev Med. 2000; 30: 146-154Crossref PubMed Scopus (291) Google Scholar In Fig 1, the concept of race and the resulting perceived hierarchy stem from the perpetuation of structural racism in legal, political, cultural, and economic institutions, which has led to residential segregation, disparate socioeconomic opportunities, and mass incarceration. Structural racism and the resulting intermediate pathways create racial inequity that contributes to interpersonal racism. The toll of interpersonal racism and discrimination additionally contributes to inequitable access to health-promoting resources (disease prevention) and health care access, as well as to chronic psychosocial stress, while also enhancing the effects of structural racism (Fig 1). In our framework, structural racism leads to proximal pathways of inequity affecting the physical and social environments. In the physical environment, Black, Latinx, and Indigenous communities are exposed disproportionately to pollutants and/or environmental hazards, occupational hazards, and poorer housing quality,21Bailey Z.D. Feldman J.M. Bassett M.T. How structural racism works — racist policies as a root cause of U.S. racial health inequities.N Engl J Med. 2021; 384: 768-773Crossref PubMed Scopus (0) Google Scholar,33Nardone A. Casey J.A. Morello-Frosch R. Mujahid M. Balmes J.R. Thakur N. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study.Lancet Planet Health. 2020; 4: e24-e31Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,34Rosenbaum E. Racial/ethnic differences in asthma prevalence: the role of housing and neighborhood environments.J Health Soc Behav. 2008; 49: 131-145Crossref PubMed Google Scholar all of which are factors with strong evidence of association with asthma and atopic dermatitis.25Brewer M. Kimbro R.T. Denney J.T. Osiecki K.M. Moffett B. Lopez K. Does neighborhood social and environmental context impact race/ethnic disparities in childhood asthma?.Health Place. 2017; 44: 86-93Crossref PubMed Scopus (22) Google Scholar,34Rosenbaum E. Racial/ethnic differences in asthma prevalence: the role of housing and neighborhood environments.J Health Soc Behav. 2008; 49: 131-145Crossref PubMed Google Scholar, 35Hughes H.K. Matsui E.C. Tschudy M.M. Pollack C.E. Keet C.A. Pediatric asthma health disparities: race, hardship, housing, and asthma in a national survey.Acad Pediatr. 2017; 17: 127-134Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 36Tackett K.J. Jenkins F. Morrell D.S. McShane D.B. Burkhart C.N. Structural racism and its influence on the severity of atopic dermatitis in African American children.Pediatr Dermatol. 2020; 37: 142-146Crossref PubMed Scopus (12) Google Scholar In the social environment, Black Latinx, and Indigenous people are more likely to experience financial strain, have less wealth, have decreased access to education, live in neighborhoods with higher rates of violence, and have a greater number of adverse childhood experiences.33Nardone A. Casey J.A. Morello-Frosch R. Mujahid M. Balmes J.R. Thakur N. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study.Lancet Planet Health. 2020; 4: e24-e31Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,37Williams D.R. Priest N. Anderson N. Understanding associations between race, socioeconomic status and health: patterns and prospects.Health Psychol. 2016; 35: 407-411Crossref PubMed Scopus (350) Google Scholar, 38Cheon C. Lin Y. Harding D.J. Wang W. Small D.S. Neighborhood racial composition and gun homicides.JAMA Netw Open. 2020; 3e2027591Crossref PubMed Scopus (3) Google Scholar, 39Logan J. The persistence of segregation in the 21st century metropolis.City Community. 2013; 12: 160-168Crossref Scopus (118) Google Scholar, 40Crouch E. Probst J.C. Radcliff E. Bennett K.J.M.S. Prevalence of adverse childhood experiences (ACEs) among US children.Child Abuse Negl. 2019; 92: 209-218Crossref PubMed Scopus (51) Google Scholar, 41Lee R.D. Chen J. Adverse childhood experiences, mental health, and excessive alcohol use: examination of race/ethnicity and sex differences.Child Abuse Negl. 2017; 69: 40-48Crossref PubMed Scopus (49) Google Scholar Several epidemiologic studies have demonstrated that these proximal pathways are associated with higher physiologic stress burden.42Brody G.H. Lei M.K. Chae D.H. Yu T. Kogan S.M. Beach S.R.H. Perceived discrimination among African American adolescents and allostatic load: a longitudinal analysis with buffering effects.Child Dev. 2014; 8: 989-1002Crossref Scopus (136) Google Scholar,43Theall K.P. Drury S.S. Shirtcliff E.A. Cumulative neighborhood risk of psychosocial stress and allostatic load in adolescents.Am J Epidemiol. 2012 Oct 1; 176: S164-S174Crossref PubMed Scopus (90) Google Scholar Independent of socioeconomic position (SEP), discrimination and segregation have also been associated with higher physiologic stress burden leading to increased inflammation.22Thakur N. Barcelo N.E. Borrell L.N. Singh S. Eng C. Davis A. et al.Perceived discrimination associated with asthma and related outcomes in minority youth: the GALA II and SAGE II studies.Chest. 2017; 151: 804-812Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar,44Carlson S. Borrell L.N. Eng C. Nguyen M. Thyne S. LeNoir M.A. Burke-Harris N. Burchard E.G. Thakur N. Self-reported racial/ethnic discrimination and bronchodilator response in African American youth with asthma.PLoS One. 2017; 12e0179091Crossref PubMed Scopus (14) Google Scholar,45Simons R.L. Lei M.K. Beach S.R.H. Barr A.B. Simons L.G. Gibbons F.X. Philibert R.A. Discrimination, segregation, and chronic inflammation: testing the weathering explanation for the poor health of Black Americans.Dev Psychol. 2018 Oct; 54: 1993-2006Crossref PubMed Google Scholar Social adversity has also produced inflammation in animal models.46Cole S.W. Human social genomics.PLoS Genet. 2014; 66: 733-767Google Scholar On the basis of this evidence, we hypothesize that these proximal pathways, along with experiences of interpersonal racism, become embedded in the biology through aberrations in the innate and adaptive immune response (Fig 1).47Krieger N. Measures of racism, sexism, heterosexism, and gender binarism for health equity research: from structural injustice to embodied harm-an ecosocial analysis.Annu Rev Public Health. 2019; 41: 37-62Crossref PubMed Scopus (47) Google Scholar,48Miller G.E. Chen E. Life stress and diminished expression of genes encoding glucocorticoid receptor and β2-adrenergic receptor in children with asthma.Proc Natl Acad Sci U S A. 2006; 103: 5496-5501Crossref PubMed Scopus (0) Google Scholar In the sections that follow, we critically appraise the gaps in our current knowledge and summarize the evidence supporting our framework, which extends from animal to human studies and spans the research fields of psychosocial stress to epidemiology. In the United States, asthma prevalence is substantially higher in Black and Indigenous populations, at rates of 10.6% and 10.7%, respectively, compared with a 7.7% prevalence within the non-Hispanic White population.7National asthma data. US Centers for Disease Control and Prevention, Atlanta, Ga2019https://www.cdc.gov/asthma/most_recent_national_asthma_data.htmDate accessed: July 7, 2021Google Scholar In addition, Black and Indigenous populations experience higher asthma morbidity, with frequent asthma attacks and higher rates of asthma-related health care utilization.11Zahran H.S. Bailey C.M. Damon S.A. Garbe P.L. Breysse P.N. Vital Signs: asthma in children — United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 149-155Crossref PubMed Google Scholar, 12Keet C.A. Matsui E.C. McCormack M.C. Peng R.D. Urban residence, neighborhood poverty, race/ethnicity, and asthma morbidity among children on Medicaid.J Allergy Clin Immunol. 2017; 140: 822-827Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 13Lowe A.A. Bender B. Liu A.H. Solomon T. Kobernick A. Morgan W. et al.Environmental concerns for children with asthma on the Navajo Nation.Ann Am Thorac Soc. 2018; 15: 745-753Crossref PubMed Scopus (10) Google Scholar, 14Washington D.M. Curtis L.M. Waite K. Wolf M.S.P.-O.M. Sociodemographic factors mediate race and ethnicity-associated childhood asthma health disparities: a longitudinal analysis.J Racial Ethn Health Disparities. 2018; 5: 928-938Crossref PubMed Scopus (11) Google Scholar When the Latinx population is considered as whole, the prevalence of asthma among Latinx people is lower (6.6%) than in most other racial and ethnic groups.7National asthma data. US Centers for Disease Control and Prevention, Atlanta, Ga2019https://www.cdc.gov/asthma/most_recent_national_asthma_data.htmDate accessed: July 7, 2021Google Scholar When examined by national subgroup, the prevalence of asthma in Mexican Americans (5.3%) is lower than in other subpopulations of Latinx people (8.5%),7National asthma data. US Centers for Disease Control and Prevention, Atlanta, Ga2019https://www.cdc.gov/asthma/most_recent_national_asthma_data.htmDate accessed: July 7, 2021Google Scholar with Puerto Ricans having the highest lifetime prevalence of asthma.49Thakur N. Borrell L.N. Ye M. Oh S.S. Eng C. Meade K. et al.Acculturation is associated with asthma burden and pulmonary function in Latino youth: the GALA II study.J Allergy Clin Immunol. 2019; 143: 1914-1922Abstract Full Text Full Text PDF PubMed Google Scholar Mexican American children also have a 2-fold increased risk of hospitalization compared with the rate for White children, which is similar to the hospitalization rate of Black children with asthma.11Zahran H.S. Bailey C.M. Damon S.A. Garbe P.L. Breysse P.N. Vital Signs: asthma in children — United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 149-155Crossref PubMed Google Scholar The lower overall prevalence of asthma in Mexican Americans likely underestimates the impact of acculturation, which reflects an adoption of cultures of the dominant society and captures the duration of time spent in the host country.49Thakur N. Borrell L.N. Ye M. Oh S.S. Eng C. Meade K. et al.Acculturation is associated with asthma burden and pulmonary function in Latino youth: the GALA II study.J Allergy Clin Immunol. 2019; 143: 1914-1922Abstract Full Text Full Text PDF PubMed Google Scholar,50Iqbal S. Oraka E. Chew G.L. Flanders W.D. Association between birthplace and current asthma: the role of environment and acculturation.Am J Public Health. 2014; 104: 175-182Crossref PubMed Google Scholar Notably, the prevalence of asthma in Mexican Americans is increasing at a greater rate than in all other racial and ethnic groups.​11Zahran H.S. Bailey C.M. Damon S.A. Garbe P.L. Breysse P.N. Vital Signs: asthma in children — United States, 2001-2016.MMWR Morb Mortal Wkly Rep. 2018; 67: 149-155Crossref PubMed Google Scholar Higher acculturation has been shown to be associated with higher prevalence of asthma in Mexican Americans49Thakur N. Borrell L.N. Ye M. Oh S.S. Eng C. Meade K. et al.Acculturation is associated with asthma burden and pulmonary function in Latino youth: the GALA II study.J Allergy Clin Immunol. 2019; 143: 1914-1922Abstract Full Text Full Text PDF PubMed Google Scholar,51Holguin F. Mannino D.M. Antó J. Mott J. Ford E.S. Teague W.G. et al.Country of birth as a risk factor for asthma among Mexican Americans.Am J Respir Crit Care Med. 2005; 171: 103-108Crossref PubMed Scopus (96) Google Scholar and other Latinx subgroups49Thakur N. Borrell L.N. Ye M. Oh S.S. Eng C. Meade K. et al.Acculturation is associated with asthma burden and pulmonary function in Latino youth: the GALA II study.J Allergy Clin Immunol. 2019; 143: 1914-1922Abstract Full Text Full Text PDF PubMed Google Scholar; similar patterns are seen in several disease outcomes.27Mcquaid E.L. Koinis-Mitchell D. Canino G.J. Acculturation.