**6. Predisposing factors**

The factors contributing to the high prevalence of asthma among inner city residents are varied. Cohen et al. [45] suggest that a key factor in this regard is the poor access to healthcare that patients in urban environments experience. This may be related to a limited number of physicians and healthcare facilities as well as limited availability of safe transportation. Limited access to care has a negative impact on most clinical conditions including the availa‐ bility of effective prenatal care. Another major predisposing factor which increases the prevalence of asthma in residents of inner cities is exposure to tobacco smoke [45]. Tobacco smoke is known to affect the rate of lung growth, clearance of secretions, and defense mech‐ anisms against particulate matter and infectious agents.

Studies have shown that children living in urban environments have a higher rate of emer‐ gency room visits and lower use of inhaled corticosteroids [46]. This may be related to lower rates of diagnosis as shown by the 1999 National Health Interview Study [34]. Specific factors that have been examined include poverty with reduced access to and quality of care [47]. The resultant additional health issues such as prematurity [48, 49] and obesity [29, 50] further confound the problem. In addition, poor housing [51] with exposure to indoor pollutants and environmental tobacco [52] plays a significant role in aggravating the condition. Finally, the psychological impact of the disease in the setting of poor resources worsens the perception among patients, impacts coping, and results in further deterioration in symptomatology [53, 54].
