title: A review of barriers to effective asthma management in Puerto Ricans: cultural, healthcare system and pharmacogenomic issues.
abstract: BACKGROUND
  Among the Hispanic community, Puerto Ricans have the highest prevalence of asthma and manifest the worst outcomes. The expected growth of the Hispanic population in the USA in the next several decades make elimination of disparate care in Puerto Rican asthmatics a matter of national importance. The purpose of this review of the literature (ROL) is to examine a variety of health system, genetic and cultural barriers in the Puerto Rican community which have created disparities in asthma care and outcomes among adult and pediatric Hispanic populations. In addition, this ROL describes several culturally sensitive, community-based educational interventions which can be used as a framework for future projects to improved asthma outcomes.
  
  
  METHODS
  Databases searched included Medline, PubMED, EBSCOhost, PsycINFO, CINAHL, Google Scholar and ERIC. Papers published in English from January 1990 to January 2012 were reviewed.
  
  
  RESULTS
  Health system policies, insurer compensation patterns, clinician attitudes and cultural values/folk remedies in the Puerto Rican community represent barriers to effective asthma management, the use of controller medication and the implementation of educational interventions. In addition, genetic factors involving the beta-2 adrenergic receptor gene, which impair the response to albuterol, appear to contribute to poorer outcomes in Puerto Rican asthmatics. In contrast, several comprehensive, community-based, culturally sensitive educational interventions such as Controlling Asthma in American Cities Project (CAACP), the Racial and Ethnic Approach to Community Health in the US Program and Healthy Hoops programs (REACH) have been described.
  
  
  CONCLUSIONS
  We believe that culturally sensitive community-based asthma education programs can serve as models for programs targeted toward Puerto Ricans to help decrease asthma morbidity. Moreover, greater sensitivity to Puerto Rican mores and folk remedies on the part of healthcare providers may improve the patient-clinician rapport and, hence, asthma outcomes. Finally, given ethnically based differences in pharmacogenomics, clinical trials targeting the Puerto Rican population may help to better define optimal asthma medication regimens in this ethnic group.
authors.affiliation: Center for Bioethics, Urban Health and Policy, Temple University School of Medicine , Philadelphia, PA , USA .
authors.forename: Norma
authors.initials: N
authors.lastname: Alicea-Alvarez
authors.forename: Brenda
authors.initials: B
authors.lastname: Swanson-Biearman
authors.forename: Steven G
authors.initials: SG
authors.lastname: Kelsen
mesh_terms: D001249:Asthma / Q000188:drug therapy* / Q000453:epidemiology / Q000235:genetics; D003469:Culture; D006266:Health Education; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006630:Hispanic or Latino / Q000208:ethnology / Q000235:genetics; D006801:Humans; D011647:Puerto Rico / Q000453:epidemiology / Q000208:ethnology