Psychology, 2010, 1: 27-34
doi:10.4236/psych.2010.11005 Published Online April 2010 (http://www.SciRP.org/journal/psych)
27
Community Violence as Psychosocial Stressor:
The Case of Childhood Asthma in Boston
Gonzalo Bacigalupe1,2, Takeo Fujiwara3,4, Sabrina Selk3, Meghan Woo3
1Department of Counseling Psychology, University of Massachusetts Boston, Boston, USA; 2Department of Psychology, University
of Deusto and Basque Foundation for Science, Ikerbasque, Bilbao, Spain; 3Department of Society and Human Development and
Health, Harvard School of Public Health, Boston, America; 4Department of Psychosocial Medicine, National Center for Child Health
Development, Tokyo, Japan.
Received February 3rd, 2010; revised February 20th, 2010; accepted February 20th, 2010.
ABSTRACT
Childhood asthma is a critical public health p roblem of urban centers in the United S tates and other industrialized na -
tions. Population-based and laboratory research studies indicate that psychosocial stress differentially affects asthma
expression. Witnessing or experiencing community violence is a psychosocial stressor that results in long-term biologi-
cal changes that may in turn contribute to asthma morbidity. This is a review of the literature that examines the expo-
sure to violence as a psychosocial stressor that is independently associated with asthma morbidity even after adjust-
ment for income, housing, and other adverse life events. In addition to acting as a physiological trigger for the disease,
community violence can also impact health behaviors and exposure to other unknown environmental risk factors. This
connection leads the authors to suggest that reducing violence and the amelioration of its impact has implications be-
yond public health. Th e City of Boston in Massachusetts serves as the context to contextualize a series of recommenda-
tions that may ameliorate and/or prevent asthma incidence and prevalence. The reduction of poverty, unemployment,
substandard hous ing, and high crime/violence rates can ha ve significant health implicatio ns for children asthma and a
decline on asthma hospitaliza tion.
Keywords: Psychosocial Stress, Violence, Asthma, Public Health
1. Introduction
Our current understanding of what causes asthma con-
tinues to remain elusive [1]. There is, however, an in-
creasing recognition of the relationship between psycho-
social stress and asthma incidence and prevalence. We
examine, first, this relationship, more specifically social
violence, as a primary environmental exposure for asthma
morbidity. And second, we discuss policy changes that
may prevent and ameliorate asthma prevalence in urban
settings including directions for future research. Child-
hood asthma is the subject of innumerous research stud-
ies. However, there are still many unknowns about its
etiology and how environmental factors contribute to the
onset and periodic episodes of this disease. Epidemiol-
ogical research, meanwhile, demonstrates a dispropor-
tionate burden of disease amongst children of low socio-
economic position [2-8]. Furthermore, specific environ-
mental exposures, such as violence, affect susceptible
populations and contribute to asthmatic attacks [8-10].
This growing body of evidence, although still prelimi-
nary, provides an alternative explanation through which
psychosocial stress as a result of exposure to violence,
acts as a primary exposure to elicit asthma symptoms.
Research into this phenomenon may help to explain the
higher burden of disease amongst children living in dis-
advantaged neighborhoods and provide insight into in-
terventions to combat this growing trend.
2. Epidemiology of Asthma
2.1 Burden of Asthma
Childhood asthma is prevalent in all major urban centers
in the United States and other industrialized nations [1,11].
In 2003, 30 million or 10.4% of Americans had asthma. 20
million had had an asthma attack in the previous year. 9
million or 12.5% of children under t he age of 18 in the U.S.
had an asthma attack in the previous year. Current trends
indicate that prevalence rates for current asthma increased
more than double from 1980 to 2003. The most substantial
increase occurred among children ages 0 to 4 years and
ages 5 to 14 years. This increasing trend in rates was
evident across race, sex, and age [12].

Community Violence as Psychosocial Stressor: The Case of Childhood Asthma in Boston 28
The medical services used to treat a sthma result in over
10.8 million physician visits, over 478,000 hospitalizations,
2 million emergency room visits, and about 28 million
missed school days annually [13]. Direct health care ex-
penditures such as physician visits, medications and other
interventions are estimated to be US$ 7.4 billion. About
US$ 3.2 billion of those direct costs are spent on asthma
care for children [14]. Indirect costs such as decreased
worker productivity, days lost from work by adults who
have asthma or care for children with asthma, and other
losses are an estimated $ 5.3 billion [15].
In Massachusetts, the first pediatric asthma surveil-
lance report released in 2004 found that has 9.2% of
children in school diagnosed with asthma. District level
prevalence varies from 2.7 to 16.2%, with prevalence as
high as 30 % in some schools [16]. This implies asthma
prevalence correlates with district level factors such as
physical or social environment. The Prevalence of active
asthma in the city of Boston was higher than the Massa-
chusetts average: one in seven, or 14% of children at-
tending school had active asthma the year 2004 with a
disproportionate burden of disease amongst students liv-
ing in disadvantaged neighborhoods. Children with
asthma average three times as many absences and use
significantly more health services than o ther children. An
estimated US$ 77 million a year are spent for both direct
and indirect costs associated with childhood asthma in
Massachusetts [16].
2.2 Children in Disadvantaged Neighborhoods:
A Vulnerable Population
Asthma prevalence and morbidity rates have drastically
risen in the United States over the past two decades.
Children living in disadvantaged neighborhoods have
been found to be particularly vulnerable to higher asthma
morbidity rates. Neighborhood disadvantage is charac-
terized by the presence of a number of community-level
stressors including poverty, underemployment, racial
discrimination, environmental inequity, limited social
capital, sub-standard housing, high crime and violence
rates [9]. Racial and income disparities in asthma mor-
bidity have been consistently reported with higher rates
of asthma hospitalization an d mortality in neighborhoods
with low median incomes and a high prevalence of mi-
nority populations [17]. The health problems of these
disadvantaged populations are not likely to be solved
without understanding the potential role of such social
determinants of health [18].
In the United States today, rates of asthma morbidity
are highest among minority children, particularly those
who reside in urban areas of low socioeconomic pos ition.
Income and poverty status has been found to be highly
related to the number of asthma attacks a child reported
in the last 12 months. 5.5% of children who were not
poor reported having an asthma attack in the last 12-
months compared to 8.0% of poor children [19]. In Bos-
ton, childhood asthma morbidity rates are also highest in
disadvantaged neighborhoods with a high percent of
black and Latino residents and low socioeconomic status
[20]. In contrast, neighborhoods with higher median in-
come had much lower rates of hospitalization.
3. Psychosocial Stress: An Environmental
Exposure
3.1 Psychosocial Stress and Asthma
Most research attributes differences in asthma morbidity
to variation in socioeconomic position. Disparities in
asthma outcomes, however, cannot be explained by so-
cioeconomic factors alone. Geographic variation has
been found in asthma morbidity among cities and
neighborhoods of similar socioeconomic status [9].
Growing evidence from population-based and laboratory
studies indicate exposure to psychosocial stress differen-
tially affects asthma expression [21]. These findings sug-
gest that exposure to psychosocial stress puts children at
greater susceptibility to asthma morbidity by disturbing
the regulation of the hypothalamic-pituitary-adrenal
(HPA) system. In this framework, psychosocial stress
can be conceptualized as an environmental exposure that
can enter the body resulting in long-term biological
changes that may contribute to asthma morbidity [22].
Research shows that psychosocial stress can also ex-
acerbate asthma symptoms by making the lungs more
susceptible to other environmental hazards. For instance,
a lowered immune response caused by stress has been
shown to increase rates of respiratory infections [23].
Stress can also influence behaviors which may lead to an
increase in a child’s exposure to potential risks such as
indoor allergens and second-hand smoke, or by making
children more vulnopin (Figure 1). Researchers are just
beginning to tease out these intertwining pathways. The
following section presents the current state of research
and the known biological impact of psychosocial stress
on asthma morbidity including violence.
3.2 The Biological Impact of Psychosocial Stress
The idea that emotions are important to asthma exacerba-
tion is not new. References to this hypothesized connec-
tion in popular culture and the scientific literature are
common. However, it is only in recent years that scien-
tists have been able to identify and to rigorously test
theories of how exogenous events are translated into
physiological responses. In this case, how psychosocial
stress can lead to an asthma attack. Current research is
examining the ways that psychosocial stress acts as a
social pollutant that can increase morbidity and exacer-
bate symptoms in children with asthma—a heuristic
mode for this pathway is shown in Figure 2.

Community Violence as Psychosocial Stressor: The Case of Childhood Asthma in Boston 29
Figure 1. Proposed framework: pathways between psycho-
social stress, neighborhood disadvantage and asthma
In humans, the primary source of physiological response
to stress stems from activation of the HPA axis. This
stimulation begins a cascading release of neurotransmitters,
neuropeptides, and hormones that stimulate a sympathetic
response to the perceived stressor. Whil e t his is generally a
beneficial reaction that helps prepare the body to react to
negative stimuli, research has shown that an over-
activation of the HPA axis, through chronic stress or acute
stressors, can have negative impacts on the body.
In the case of asthma, it is believed that the deleterious
physical effects are mediated at least in part by the
shared pathway of activation of th e autonomic control of
the airways in both asthma and stress responses. This
overlap can be used to explain how the parasympathetic
stress response might influence lung tone. Studies exam-
ining exposure to stressors have used vagal reactivity in
response to stress as a measure of emotion induced air-
way constriction [24]. The mechanism suggested by this
relationship is that the presence of an acute stress event
will trigger a parasympathetic response including vagal
activation and a corresponding rapid release of cate-
cholamine leading to airway constriction. However, this
is not the only way that stress has been implicated in ex-
acerbating asthmatic symptoms [25].
The second physiological co mponent of an asth ma attack
Figure 2. Hypothesized pathways: biological impact of psychosocial stress & asthma
Psychosocial
Stressor
Activation of HPA Axis
(Release of Neurotransmitters)
Parasympathetic Stress
Response Alteration of Immune
Functioning
Vagal Activation
Release of
Catecholamines
Lung Inflam-
mation Bronchocon-
striction
Suppression of
Immune System
Increase in
Respiratory
Infections
Activation of
Immune System
Increase in Cyto-
kines and Lym-
phocytes
Increased
Allergic Re-
sponse
Inflammation of
Lung Tissues
Higher Exposure to
Environmental
Hazards
(Outdoor/Indoor
Pollution)
Higher Psychosocial
Stress
Higher Prevalence of
Asthma
Children Living in
Disadvantaged
Neighborhoods
Higher Exposure to
Violence

Community Violence as Psychosocial Stressor: The Case of Childhood Asthma in Boston 30
is believed to be more closely associated with immune
function. Stress induced alterations in immune response
can be complex and may include both activation and
suppression of the immune system. Some suggest that
this alteration in lymphocyte creation may be an impor-
tant component to the etiology of asthma in children
raised in stressful environments [26]. These immune al-
terations are especially critical in the early development
of a child’s immune system when the Th2 polarization of
their immune system and Th2 reactivity to allergens de-
velops [27,28]. Although the direct role of stress on Th2
levels is still being investigated, there is evidence that
parental report of life stress is associated with onset of
wheezing in children less than one year of age [29].
3.3 Violence: A Primary Psychosocial Stressor
Children living in disadvantaged neighborhoods are at
higher risk for asthma morbidity largely resulting from
greater exposure to psychosocial stressors. We have
characterized psychosocial stress as an environmental
exposure that directly impacts the physiological expres-
sion of asthma. A clearer understanding of the most
relevant sources of psychosocial stress that impact asth-
ma morbidity is needed to adequately address interven-
tions and policy initiativ es improving psychosocial stress
exposure in this vulnerable population. The literature to
date has primarily focused on exposure to community
violence as the principal psychosocial factor impacting
asthma morbidity among children living in disadvan-
taged neighborhoods [9,26]. For the purposes of this pa-
per we characterize community violence as direct expo-
sure through victimization or through witnessing of vio-
lence. We primarily refer to violence that occurs outside
the home rather than domestic violence, although we
acknowledge exposure to domestic violence could have
similar effects on asthma morbidity.
The psychosocial stressors associated with neighbor-
hood disadvantage are numerous; however, the preva-
lence of chronic community violence is a specific and
extreme stressor confronting the urban poor [26]. Like-
wise, the prevalence of high crime and violence is a
critical component defining neighborhood disadvantage.
As a result, exposure to violence has a direct impact on
asthma morbidity rather than simply serving as a marker
for low socioeconomic position. It has been independ-
ently associated with asthma morbidity even after ad-
justment for income, housing problems, and other ad-
verse life events [30].
Certain populations face a greater deleterious effect of
stress when facing daily life experiences that are unpre-
dictable or uncontrollable [31]. This is critically impor-
tant to asthma morbidity in disadvantaged neighb orhoods
given that living in a violent community has been associ-
ated with a chronic pervasive atmosphere of fear and the
perceived threat of violence. Children and families ex-
posed to community violence are more likely to view
their world as being out of their control and to suffer
more harmful effects from stress [26-30].
Community violence is pervasive. Studies have dem-
onstrated that children living in urban disadvantaged
neighborhoods are exposed to high rates of violence.
More than 46% of children and adolescents in the U.S.
reported being the direct victim of violence and over
60% reported having been exposed to community vio-
lence [32]. In an inner-city cohort in Chicago, Ilinois,
42% of children ages 7-13 had seen someone shot while
37% had seen someone stabbed [33]. In Boston, one
study examined the prevalence of witnessing violence
among children ages 1-5 from the pediatric primary care
clinic at Boston City Hospital. Th e res ear cher s fo und th at
10% of children witnessed a knifing or shooting; 18%
witnessed shoving, kicking, or punching; and 47% heard
gunshots [34]. Similarly, in a national cohort sample
from large U.S. cities, children had a 2 fold increased
risk of asthma when exposed to interpersonal vio lence at
home [3].
3.4 Impact of Exposure to Violence on Asthma
Violence affects asthma morbidity through many path-
ways. In addition to acting as a physiological trigger for
the disease, community violence can also impact health
behaviors and exposure to other unknown environmental
risk factors [9]. For example, parents and caretakers
who are worried about their children’s safety may re-
strict outdoor activities leading to a greater exposure to
indoor allergens. Given that the degree of housing dis-
repair has been associated with increased cockroach
allergen levels (a known risk factor for increased
asthma), children who live in disadvantaged neighbor-
hoods and must stay indoors have higher rates of asthma
morbidity [35]. Keeping children indoors may also re-
strict their ability to develop support networks. Addition-
ally, it has been suggested that fear of crime fosters a
distrust of others. Both of these factors can lead to social
isolation and a diminishment of stress buffering factors
such as social networks [26].
This exposure may also impact th e adoption of coping
behaviors by household members such as smoking, an-
other known trigger for asthma. One study examining
increased rates of smoking in African American house-
holds found that the strongest predictor of smoking was a
report of high stress levels [36]. In a study of tobacco use
among adolescents, smoking was strongly associated
with adverse childhood experiences. This indicates nico-
tine may be adopted as a pharmacological coping device
for the negative emotional, neurobiological, and social
effects of adverse childhood experiences [37].
Finally, a violent environment may also impact com-
pliance to asthma treatments and medical follow-up.
Caregivers may fear making a trip to a pharmacy or me-

Community Violence as Psychosocial Stressor: The Case of Childhood Asthma in Boston 31
dical provider for treatment due to fear of personal safety
in a violent neighborhood. Additionally, pharmacies may
not stay open at night in high crime areas, limiting im-
mediate or emergency access to medication. As men-
tioned previously it has been sugg ested that families who
live in a violent environment are more likely to feel like
their world is out of control. Helplessness has been
linked to depression, which may limit the caretaker’s
ability to buffer the detrimental effects of community
violence in the lives of their children [38]. Caretakers
living in violent communities frequently express a sense
of helplessness and frustration in their inability to p rotect
their children.
4. Policy Recommendations
Prioritizing the reduction of psychosocial stressors, here
described as community violence, in vulnerable neighbor-
hoods introduces a ben eficial externality: th e reduction of
asthma morbidity among children. This morbidity reduc-
tion, in turn, would bring other forms of economic, social,
and health benefits that are directly and indirectly related
to the disease under study. In Boston and other urban
settings, attempts at controlling violence have always
been accompanied by large community initiatives. In
conjunction with reducing psychosocial stress through
violence prevention and control measures, making health
care accessible is a core component in reducing other
forms of psychosocial stress. Enhancing quality health
care accessibility for children with asthma and reduction
of known indoor environmental exposures are indispen-
sable in the long-term control of asthma.
Asthma morbidity is the result of a complex interplay
of influences operating at several levels, including the
individual, the family, and the community. Similarly,
decisions regarding policies and programs that would
reduce violence and the amelioration of its impact have
implications beyond public health. Often policies that
address violence prevention and control and health care
access and quality operate in distinct legislative and
regulatory worlds. To reformulate these policies into an
integrated process, legislators should include psychoso-
cial stressors like neighborhood violence in venues be-
yond the realm of law enforcement.
We recognize the complexity of preventing violence
and asthma as well as the need for a variety of policies in
the realm of environmental justice, human services, and
law enforcement. However, none of these factors alone
will suffice. For example, reinforcing police presence
may not necessarily reduce the prevalence of psychoso-
cial stress since police presence by itself may increase
community stigma and fear. Our recommendations rec-
ognize the need for intersectorial policies to simultane-
ously address exposure to violence as well as prevention
and treatment of asthma morbidity. There is strong evi-
dence for violence acting as a significant psychosocial
stressor however the exact mechanisms remain unclear
introducing uncertainty in the risk analysis [39]. The pr e-
cautionary principle [40] indicates that policy makers
should develop the means to include considerations of
the role that psychosocial stress plays on asthma morbid-
ity within governmental and social policy as well as
through recommendations to individuals [18]. We have
categorized the recommendations under three areas: re-
search and information, community participation, and
public health initiatives.
4.1 Research & Information
Exposure to violence as a risk to the health of children
has been the source of a growing number of research
initiatives. These are promising activities but more re-
search is needed to assess the specific exposure pathway
and its connection with the known factors that determine
health and health care disparities in asthma morbidity. At
the present, we are only able to hypothesize that violence
acts as a compounding or additive mechanism in making
children more vulnerable to the impact of environmental
pollutants (indoor and outdoor)—likely through its im-
pact on the health seeking behavior of parents and chil-
dren under trea tment.
In addition to more methodologically sound research
to identify the morbidity mechanisms; there is also a
need for greater data of asthma morbidity amongst chil-
dren as well as information on trends over time. To fill
this need, the City of Boston should be a leader in efforts
to establish a centralized state asthma data registry. This
registry should include a system of surv eillance by which
psychosocial stressors assessment is routinely integrated
into the treatment of children arriving with asth ma crises
to emergency rooms and local community health centers.
4.2 Community Participation
The City of Boston is experiencing resurgence in the
number of homicides and other forms of social violence
despite previous successful efforts at reducing its preva-
lence. There is a rich opportunity to link the renewed
efforts at preventing and controlling violence with an
awareness and identification of the psychosocial stressors
directly linked to asthma morbidity that offers a signifi-
cant opportunity to strength en thos e efforts. These efforts
may include: incorporating asthma morbidity prevention
as another dimension in the Boston strategies to confront
neighborhood violence, i.e., Boston Strategic Multi-
Agency Response Teams, Youth Center Initiatives, among
others [41]; creating collaborative research and interven-
tion initiatives with housing collaborative health initia-
tives to incorporate psychosocial stress as part of the
surveillance and educational intervention activities en-
gaging with community participants in the integration of
evidence based knowledge into program efforts; incor-

Community Violence as Psychosocial Stressor: The Case of Childhood Asthma in Boston 32
porating the psychosocial stress agenda into the Asthma
Planning Collaborative Initiative which has as a goal to
develop a Massachusetts State Plan for Asthma.
4.3 Public Health Initiatives
Asthma is one of many chronic diseases in the United
States in which disparities in treatment and access to care
have been documented [42]. The City of Boston as part
of its plans which includ e redu cing h ealth disp arities [43]
could provide further funding for: community based par-
ticipatory research [44-46] with the goal of developing
strategies to reduce violence in urban neighborhoods
with high incidence of asthma morbidity; research pro-
jects that use a positive dev iance model [47,48] to inves-
tigate how some families and community groups have
been able to develop effective strategies and positively
cope despite the witnessing of social violence in their
neighborhoods; curricular initiatives to develop educa-
tional materials for others to learn from those community
research experiences.
Second, in addition to these community research ini-
tiatives, the healthcare needs of patients need to be ad-
dressed. Social violence inhibits the ability of parents of
ensuring the safety of their children and leading to emo-
tionally unavailability d ue to fear and trauma [49]. These
healthcare needs could be satisfied via the development
of a comprehensive program to support and empower
parents as the key factor in developing resilience and
mediate the effects of children’s exposure to violence;
designing psych osocial and community interven tions that
help parents to reduce the psychological strain produced
by a sense of lack of control and agency in their lives;
fostering the development of community cohesion and
trust to provide parents with a social support network that
counteracts the deleterious effects of social violence;
collaborating with child welfare institutions and collabo-
rative family initiatives to assess and strengthen appro-
priate prevention and treatment of asthma morbidity
among the children served by these programs; collecting
information about asthma morbidity from programs that
address the psychological needs of children that have
identified as having witnessed or victimized by violence
in their homes and/or neighborhoods.
Third, universal health care coverage is synergetic
with recommendations directly addressing health care
access and quality in the case childhood asthma. As part
of these efforts, medical insurers would include as part of
their plans asthma medical supplies and education spe-
cialists providing consistent education, expertise and
support for patient to successfully identify and manage
asthma; and, ameliorating the transportation and other
health care access barriers. Examples of these efforts
include a program like a roving clinic on wheels for
asthmatic school children to provide a comprehensive
asthma management strategy [50,51].
Policies that reduce poverty, unemployment, substan-
dard housing, and high crime/violence rates may have
significant health i mplications for child ren and ultimately
have a direct impact on asthma hospitalization [2]. Simi-
larly, policies that regulate outdoor and indoor air pollu-
tion would also affect asthma morbidity. In addition to
direct impacts on community residents, crime and vio-
lence (or the lack thereof) can be used as indicators of
collective well-being and social cohesion within a com-
munity. Furthermore, the conditions known to be associ-
ated with violence exposure are related to having ex-
perienced stress [52,53], and chronic violence exposure
has been conceptualized as a pervasive environmental
stressor imposed on already vulnerable populations [4,10]
including asthma [5,8].
5. Conclusions
Asthma is a highly prevalent and increasing health chal-
lenge for urban neighborhoods across the nation and
within Boston. Exposure to community violence creates
high levels of psychosocial stress in neighborhoods,
which are associated with a higher burden of childhood
asthma. The theory of embodiment suggests that the
body can often tell a story about the conditions of our
lives [54,55]. We argue that asthma is the embodiment of
the exposure to the environmental pollutant of violence
in children’s lives. There are many pathways through
which this experience acts upon the body. Lack of social
support, fear and stigma, greater exposure to indoor pol-
lutants and allergens, as well as impacts on health be-
haviors are often part of living in environments where
exposure to violence is high. However, it is violence it-
self that acts as a primary predictor of the psychosocial
stress that is translated into biological changes in the res-
piratory and immune systems of children living in these
neighborhoods. While there are uncertainties about the
exact mechanisms behind this relationship, the precau-
tionary principle should guide our actions towards mak-
ing policies to protect the health of children now.
Based on the evidence and the burden of disease, we
analyzed potential interventions that include: continued
research and data gathering; increasing community par-
ticipation in measures to combat violence and revitalize
neighborhoods; and initiation of public health programs
to address both violence prevention and decreasing bar-
riers to asthma care and treatment. True change in
asthma morbidity can only o ccur when the full contex t in
which children live their lives is considered, and this
must include a realization of the important role that psy-
chosocial stress and violence play in this disease.
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