Home is Where the Triggers Are: Increasing Asthma Control by Improving the Home Environment

Ladders and stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions

Introduced in 2007 by the Nuffield Council on Bioethics, the intervention ladder has become an influential tool in bioethics and public health policy for weighing the justification for interventions and for weighing considerations of intrusiveness and proportionality. However, while such considerations are critical, in its focus on these factors, the ladder overemphasises the role of personal responsibility and the importance of individual behaviour change in public health interventions. Through a study of vaccine hesitancy and vaccine mandates among healthcare workers, this paper investigates how the ladder obscures systemic factors such as the social determinants of health. In overlooking these factors, potentially effective interventions are left off the table and the intervention ladder serves to divert attention away from key issues in public health. This paper, therefore, proposes a replacement for the intervention ladder-the intervention stairway. By broadening the intervention ladder to include systemic factors, the stairway ensures relevant interventions are not neglected merely due to the framing of the issue. Moreover, it more accurately captures factors influencing individual health as well as allocations of responsibility for improving these factors.

Housing typologies and asthma: a scoping review

Asthma is related to triggers within the home. Although it is recognised that triggers likely occur due to characteristics of housing, these characteristics have not been comprehensively reviewed, and there is a paucity of housing-focused interventions to reduce asthma and asthma symptoms. Following five steps identified by Arksey and O'Malley, we conducted a scoping review of published evidence on the associations between asthma and housing characteristics. We searched three electronic databases (PubMed, Scopus, Web of Science), identifying 33 studies that met our inclusion criteria. Through an iterative approach, we identified nine housing characteristics relevant to asthma onset or exacerbation, categorised as relating to the surrounding environment (location), the house itself (dwelling), or to conditions inside the home (occupancy). We conceptualise these three levels through a housing typologies framework. This facilitates the mapping of housing characteristics, and visualises how they can cluster and overlap to exacerbate asthma or asthma symptoms. Of the three levels in our framework, associations between asthma and locational features were evidenced most clearly in the literature reviewed. Within this category, environmental pollutants (and particularly air pollutants) were identified as a potentially important risk factor for asthma. Studies concerning associations between dwelling features and occupancy features and asthma reported inconsistent results, highlighting the need for greater research in these areas. Interpreting housing-related asthma triggers through this framework paves the way for the identification and targeting of typologies of housing that might adversely affect asthma, thus addressing multiple characteristics in tandem rather than as isolated elements.

Impact of Hurricane Matthew on a Cohort of Adolescents With Asthma in North Carolina

OBJECTIVE

The aim of this study was to look at a cohort of adolescents who were already enrolled in a randomized controlled trial to see (1) how demographics were associated with hurricane impact, and (2) how hurricane impact was associated with reported asthma quality of life.

METHODS

One hundred fifty-one adolescents ages 11-17 and their parents enrolled in a randomized controlled trial at 2 sites in southeastern North Carolina completed questions about asthma quality of life, demographics, and the impact of Hurricane Matthew.

RESULTS

The most common effects of Hurricane Matthew were that the family's home was damaged or flooded (32.5%), the school was damaged or flooded (31.8%), and the home had mold or mildew as a result of flooding or damage (25.8%). Problems with access to care were more common for families whose adolescent was non-White (P = 0.04), on Medicaid (P = 0.05), or if the family spoke Spanish at home (P < 0.001). Being affected by the hurricane was negatively associated with asthma quality of life.

CONCLUSIONS

Hurricane Matthew had significant impact on the health of adolescents with asthma in the affected region, especially in the most vulnerable populations. Providers should ensure that families of adolescents with asthma have a hurricane plan to mitigate impact on their children's health.

Evaluating the effect and user satisfaction of an adapted and translated mobile health application ASTHMAXcel© among adults with asthma in Pune, India

OBJECTIVE

ASTHMAXcel^© is a mobile application previously shown to improve asthma knowledge, control, and quality of life. In this study, we translated the application to Marathi for pilot testing in Pune, India in order to evaluate its impact on user satisfaction and asthma knowledge among adult asthma patients.

METHODS

ASTHMAXcel^© was adapted to Marathi with the help of asthma patients and clinicians from Bharati Hospital. 57 different asthma patients were then recruited and received the Asthma Knowledge Questionnaire (AKQ), Asthma Control Questionnaire (ACQ), and Mini Asthma Quality of Life Questionnaire (Mini-AQLQ) to complete at baseline. Study participants then completed the adapted ASTHMAXcel^© application. Post-intervention, participants filled out a post-AKQ and Questionnaire for User Interface Satisfaction (QUIS). A subset of participants was also interviewed for qualitative feedback. Paired t-tests and Pearson's correlation were used for statistical analysis.

RESULTS

Mean AKQ improved from 5.0+/-2.4 to 12.4+/-1.6 (p = 0.0001). QUIS results revealed that participants were highly satisfied with the application, scoring an average of 50 out of 54 maximum points. Better baseline asthma control was correlated with greater overall experience with the application (-0.110, p = 0.0417). Finally, the qualitative feedback revealed four themes for future refinement.

CONCLUSION

The adapted version of ASTHMAXcel^© was linked to significant improvement in patient asthma knowledge and a high level of user satisfaction. These results support the potential utility of mHealth applications in promoting guideline-based asthma care in India. However, further studies are needed to establish a causal relationship between ASTHMAXcel^© and improved clinical outcomes.

Risk of Developing Asthma After Lower Respiratory Tract Infections with Respiratory Syncytial Virus During Childhood

Background: Recent studies indicate causal relationship between infection by respiratory syncytial virus (RSV) and bronchial asthma. We evaluated the incidence of bronchial asthma in children with RSV positive infection early in their childhood in a nation-wide cohort study. Methods: Children (aged between one month and 15 years) were evaluated for the presence of RSV infection when they presented with one or more acute respiratory tract infection symptoms (fever, cough, cold and wheezing) in a major tertiary care hospital in the Kingdom of Bahrain during a period of seven years. RSV detection was done using nasopharyngeal secretion (NPS) samples by direct antigen detection immunofluorescence technique. Number of children who were later diagnosed with asthma was recorded. Serum IgE levels were estimated. Risk of developing bronchial asthma is represented using relative risk (RR) [95% CI]. Children with asthma without prior RSV infection from the same population formed the historical control. Results: A total of 3782 children diagnosed with respiratory tract infection were recruited. We observed that RSV infection at younger age (during infancy) and severe infection were significantly associated with asthmatic episodes RR [95% CI]: 7 [5.5, 8.2]. Additionally, asthmatics with prior RSV infection had significantly higher total IgE levels (167 ± 37 IU/ml) compared to those without RSV infection (92 ±17 IU/ml). Mean (SD) age of children developing asthma with prior RSV infection was 0.7 (0.42) years compared to the historical control [6.8 (3.8) years] and was statistically significant. Conclusion: Infants with RSV infection have an increased risk of developing bronchial asthma later in the childhood. The more severe the RSV infection, the greater is the severity of bronchial asthma as indicted by serum IgE levels. Asthma in children with RSV infection occurs at much younger age compared to those without RSV infection.

Differential immunomodulatory effects of six pesticides of different chemical classes on human monocyte-derived macrophage functions

Exposure to pesticides through eyes, skin, ingestion and inhalation may affects human health by interfering with immune cells, such as macrophages. We evaluated, in vitro, the effect of six pesticides widely used in apple arboriculture on the functions of human monocyte-derived macrophages (hMDMs). hMDMs were cultured for 4 or 24 h with or without pesticides (0.01, 0.1, 1, 10 μmol.L^-1). We showed that chlorpyrifos, thiacloprid, thiophanate, boscalid, and captan had little toxic effect at the tested concentrations, while dithianon had low-cytotoxicity at 10 μmol.L^-1. While boscalid showed no effect on hMDMs function, thiophanate (0.01 μmol.L^-1) stimulated with TPA and thiacloprid (1, 10 μmol.L^-1) stimulated with zymosan activated ROS production. Chlorpyrifos, dithianon, and captan inhibited ROS production and TNF-α, IL-1β pro-inflammatory cytokines. We established that dithianon (0.01-1 μmol.L^-1) and captan (0.1, 1 μmol.L^-1) induced mRNA expression of NQO1 and HMOX1 antioxidant enzymes. Dithianon also induced the mRNA expression of catalase, superoxide dismutase-2 at 10 μmol.L^-1. Together, these results show that exposure to chlorpyrifos, dithianon, and captan induce immunomodulatory effects that may influence the disease fighting properties of monocytes/macrophages while pesticides such as thiacloprid, thiophanate and boscalid have little influence.

Indoor air quality impacts of residential mechanical ventilation system retrofits in existing homes in Chicago, IL

Mechanical ventilation systems are used in residences to introduce ventilation air and dilute indoor-generated pollutants. A variety of ventilation system types can be used in home retrofits, influencing indoor air quality (IAQ) in different ways. Here we describe the Breathe Easy Project, a >2-year longitudinal, pseudo-randomized, crossover study designed to assess IAQ and adult asthma outcomes before and after installing residential mechanical ventilation systems in 40 existing homes in Chicago, IL. Each home received one of three types of ventilation systems: continuous exhaust-only, intermittent powered central-fan-integrated-supply (CFIS), or continuous balanced system with an energy recovery ventilator (ERV). Homes with central heating and/or cooling systems also received MERV 10 filter replacements. Approximately weeklong field measurements were conducted at each home on a quarterly basis throughout the study to monitor environmental conditions, ventilation operation, and indoor and outdoor pollutants, including size-resolved particles (0.3-10 μm), ozone (O₃), nitrogen dioxide (NO₂), carbon dioxide (CO₂), carbon monoxide (CO), and indoor formaldehyde (HCHO). Mean reductions in indoor/outdoor (I/O) ratios across all systems after the intervention were approximately 12% (p = 0.001), 10% (p = 0.008), 42% (p < 0.001), 39% (p = 0.002), and 33% (p = 0.007), for CO₂, NO₂, and estimated PM₁, PM_2.5, and PM₁₀, respectively. There was a reduction in I/O ratios for all measured constituents with each type of system, on average, but with varying magnitude and levels of statistical significance. The magnitudes of mean differences in I/O pollutant concentrations ratios were generally largest for most pollutants in the homes that received continuous balanced with ERV and smallest in the homes that received intermittent CFIS systems, with apparent benefits to providing ventilation continuously rather than intermittently. All ventilation system types maintained similar indoor temperatures during pre- and post-intervention periods.

Overview of severe asthma, with emphasis on pediatric patients: a review for practitioners

Asthma is the most common life-threatening chronic disease in children. Although guidelines exist for the diagnosis and treatment of asthma, treatment of severe, pediatric asthma remains difficult. Limited studies in the pediatric population on new asthma therapies, complex issues with adolescence and adherence, health disparities, and unequal access to guideline-based care complicate the care of children with severe, persistent asthma. The purpose of this review is to provide an overview of asthma, including asthma subtypes, comorbidities, and risk factors, to discuss diagnostic considerations and pitfalls and existing treatments, and then present existing and emerging therapeutic approaches to asthma management. An improved understanding of asthma heterogeneity, clinical characteristics, inflammatory patterns, and pathobiology can help further guide the management of severe asthma in children. More studies are needed in the pediatric population to understand emerging therapeutics application in children. Effective multimodal strategies tailored to individual characteristics and a commitment to address risk factors, modifiers, and health disparities may help reduce the burden of asthma in the USA.

Climbing Mountains and Avoiding Slippery Slopes: Challenges in Constructing Measures of Children's Environments

ABSTRACT

Constructing valid, useful measures of children's environments is critical for advancing knowledge about relations between environmental conditions and child well-being. The approach to constructing useful measures of children's environments varies somewhat from the approach needed to construct valid, useful measures of children's personal characteristics. The commentary includes a review of literature on the distinction between reflective indicators and causal/formative indicators because it applies to the construction of measures of human environments. It also offers suggestions on how to select indicators for inclusion in measures of the environment and how to select assessments of child outcomes for validating measures of children's environments.

Families as a Cornerstone in 21st Century Public Health: Recommendations for Research, Education, Policy, and Practice

Families are vastly overlooked in US initiatives to promote population health and health equity despite being the most proximal context for health across the life course. We urge the public health sector to take the lead in recognizing families as essential for promoting 21st century population health. We highlight ways families influence health by providing context, care, continuity, and connections. The dual private and public aspect of families has contributed to how they have been overlooked in the public health sector. We provide recommendations for better integrating families into population health initiatives through national health goals, research, education, policy, and practice.

Effect of Ambient Air Pollution on Hospital Readmissions among the Pediatric Asthma Patient Population in South Texas: A Case-Crossover Study

Few studies have evaluated the association between ambient air pollution and hospital readmissions among children with asthma, especially in low-income communities. This study examined the short-term effects of ambient air pollutants on hospital readmissions for pediatric asthma in South Texas. A time-stratified case-crossover study was conducted using the hospitalization data from a children’s hospital and the air pollution data, including particulate matter 2.5 (PM_2.5) and ozone concentrations, from the Centers for Disease Control and Prevention between 2010 and 2014. A conditional logistic regression analysis was performed to investigate the association between ambient air pollution and hospital readmissions, controlling for outdoor temperature. We identified 111 pediatric asthma patients readmitted to the hospital between 2010 and 2014. The single-pollutant models showed that PM_2.5 concentration had a significant positive effect on risk for hospital readmissions (OR = 1.082, 95% CI = 1.008–1.162, p = 0.030). In the two-pollutant models, the increased risk of pediatric readmissions for asthma was significantly associated with both elevated ozone (OR = 1.023, 95% CI = 1.001–1.045, p = 0.042) and PM_2.5 concentrations (OR = 1.080, 95% CI = 1.005–1.161, p = 0.036). The effects of ambient air pollutants on hospital readmissions varied by age and season. Our findings suggest that short-term (4 days) exposure to air pollutants might increase the risk of preventable hospital readmissions for pediatric asthma patients.

Design of a home-based intervention for Houston-area African-American adults with asthma: Methods and lessons learned from a pragmatic randomized trial

A growing body of evidence demonstrates that home-based, multicomponent interventions can effectively reduce exposures to asthma triggers and decrease asthma symptoms. However, few of these studies have targeted adults. To address this and other research gaps, we designed and implemented a pragmatic randomized clinical trial, the Houston Home-based Integrated Intervention Targeting Better Asthma Control (HIITBAC) for African Americans, to assess the effectiveness of a home-based intervention to improve asthma control and quality of life in African-American adults-a population disproportionately affected by asthma. The primary goals were to help participants reduce allergens and irritants in their homes and better manage their disease through knowledge, improved medication use, and behavior change. HIITBAC had two groups: clinic-only and home-visit groups. Both groups received enhanced clinical care, but the home-visit group also received a detailed home assessment and four additional home visits spaced over roughly one year. We recruited 263 participants. Of these, 152 (57.8%) were recruited through electronic health record data, 51 (19.4%) through Emergency Medical Services data, and 60 (22.8%) through other efforts (e.g., emergency departments, community events, outreach). Seventy participants (26.6%) were lost to follow up, substantially more in the home-visit than in the clinic-only group. We describe the HIITBAC methodology and cohort, discuss lessons learned about recruitment and retention, and highlight adaptations we implemented to address these lessons.

Prevention of Allergic Asthma with Allergen Avoidance Measures and the Role of Exposome

PURPOSE OF REVIEW

It is well known that combination of sensitization and exposure to inhaled environmental allergens is related to both the development and elicitation of symptoms of asthma and that avoidance of allergens would exert beneficial effects in the prevention and control of the disease. Other important factors include the relevance of other allergens, exposure to sensitizing agents also outside patient's home, exposure to irritants (like chemical air pollutants), and the involvement of the patient with a correct education. It is also likely that clinical phase of allergic airway disease and the degree of airways remodeling represent relevant factors for the clinical outcome of allergen avoidance procedure. We reviewed existing evidence on prevention of asthma through allergen avoidance.

RECENT FINDINGS

The management of respiratory allergy is a complex strategy (including prevention, drugs, immunological, and educational interventions). In addition, it is difficult in real life to distinguish the efficacy of single interventions. However, a combined strategy is likely to produce clinical results. A combined strategy is likely to produce satisfactory management of asthma. Allergens are an important trigger factor for the development of symptoms of respiratory allergy, and avoidance measures are able to reduce allergen levels. It is likely that clinical phase of allergic airway disease and the degree of airways remodeling represents relevant factors for the clinical outcome of allergen avoidance procedures. Considering the management of respiratory allergy is a complex strategy; it is difficult in real life to distinguish the efficacy of single interventions. However, further studies better quantifying the effects of allergens are needed.

Assessing Indoor Environmental Control Practices by Race/Ethnicity Among Children With Asthma in 14 US States and Puerto Rico, 2013-2014

INTRODUCTION

In the United States, children in Puerto Rico and non-Hispanic black children in the mainland US have a higher burden of asthma than non-Hispanic white children in the mainland US. We examined indoor environmental control (IEC) practices that reduce asthma triggers, by race/ethnicity among children in the mainland US and Puerto Rico.

METHODS

We used 2013 and 2014 data from the Behavioral Risk Factor Surveillance System Asthma Call-back Survey Child Questionnaire from 14 states and Puerto Rico to measure the association between race/ethnicity and IEC practices, adjusting for sociodemographic covariates, among children identified as ever receiving an asthma diagnosis. Racial/ethnic groups were compared in 14 US states using aggregated data. Separate analyses compared IEC practices for children diagnosed with asthma in Puerto Rico with children of all races/ethnicities diagnosed with asthma in 14 states.

RESULTS

Among households in 14 US states that had a child with asthma, non-Hispanic black children were more likely than non-Hispanic white children to use an air purifier (36.8% vs 25.2%; adjusted odds ratio [aOR] = 2.0; 95% confidence interval [CI], 1.3-3.2) and avoid pets in the bedroom (87.9% vs 58.3%; aOR = 4.5; 95% CI, 2.3-8.8). Children in Puerto Rico were more likely than children in 14 states to use dust mite-impermeable pillow covers (53.7% vs 36.4%; aOR = 3.6; 95% CI, 1.8-7.1) and mattress encasements (60.3% vs 30.3%; aOR = 2.4; 95% CI, 1.2-4.8).

CONCLUSION

IEC practices such as using air purifiers, pillow covers, mattress encasements, and avoiding pets in the bedroom vary by race/ethnicity among children with asthma. These findings show that vulnerable populations are using IEC practices, but asthma prevention and control measures should continue to be assessed.

The experience of patients and family caregivers in managing pneumoconiosis in the family context: A study protocol

AIM

This study aims to explore the illness experience and needs of patients with pneumoconiosis and the caregiving experience of their respective family caregivers.

DESIGN

This is an exploratory qualitative study.

METHODS

Participants will be recruited during the annual patient interview with purposive sampling. Those with a confirmed diagnosis of pneumoconiosis for at least 1 year will be eligible. Patients with different levels of physical dependency will be recruited. The respective family caregivers of these patients, who are ≥21 years of age, assuming the role as primary caregivers of a pneumoconiosis patient will also be invited to join. In-depth interviews will be conducted in patients' home separately for patients and their caregivers and a home environment assessment will also be undertaken. The interview data will be transcribed verbatim, managed with the software NVivo 11 and analysed with content analysis. The ethical approval has obtained, and this study is supported by a research grant from the Pneumoconiosis Compensation Fund Board of Hong Kong on 14 August 2018.

DISCUSSION

This study will advance the knowledge on how pneumoconiosis patients and their family caregivers manage the disease in the family context. The findings of this study can inform the development of a family-oriented care model to support the pneumoconiosis patients and their family caregivers to manage this condition better.

IMPACT STATEMENT

Pneumoconiosis is the most common type of occupational lung disease in the Chinese population. These patients require long-term comprehensive services and support to assist their disease self-management. However, little is known about how these patients and their family caregivers manage the disease in the family context. The current study addresses this gap by exploring patients' illness experience and their family members' caregiving experience, which is timely to inform the design of family-oriented model of care to support this clinical cohort.

CLINICAL TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov (NCT04022902).

The Economic Burden of Asthma in the United States, 2008-2013

RATIONALE

Asthma is a chronic disease that affects quality of life, productivity at work and school, and healthcare use; and it can result in death. Measuring the current economic burden of asthma provides important information on the impact of asthma on society. This information can be used to make informed decisions about allocation of limited public health resources.

OBJECTIVES

In this paper, we provide a comprehensive approach to estimating the current prevalence, medical costs, cost of absenteeism (missed work and school days), and mortality attributable to asthma from a national perspective. In addition, we estimate the association of the incremental medical cost of asthma with several important factors, including race/ethnicity, education, poverty, and insurance status.

METHODS

The primary source of data was the 2008-2013 household component of the Medical Expenditure Panel Survey. We defined treated asthma as the presence of at least one medical or pharmaceutical encounter or claim associated with asthma. For the main analysis, we applied two-part regression models to estimate asthma-related annual per-person incremental medical costs and negative binomial models to estimate absenteeism associated with asthma.

RESULTS

Of 213,994 people in the pooled sample, 10,237 persons had treated asthma (prevalence, 4.8%). The annual per-person incremental medical cost of asthma was $3,266 (in 2015 U.S. dollars), of which $1,830 was attributable to prescription medication, $640 to office visits, $529 to hospitalizations, $176 to hospital-based outpatient visits, and $105 to emergency room visits. For certain groups, the per-person incremental medical cost of asthma differed from that of the population average, namely $2,145 for uninsured persons and $3,581 for those living below the poverty line. During 2008-2013, asthma was responsible for $3 billion in losses due to missed work and school days, $29 billion due to asthma-related mortality, and $50.3 billion in medical costs. All combined, the total cost of asthma in the United States based on the pooled sample amounted to $81.9 billion in 2013.

CONCLUSIONS

Asthma places a significant economic burden on the United States, with a total cost of asthma, including costs incurred by absenteeism and mortality, of $81.9 billion in 2013.

High burden of atopy in immigrant families in substandard apartments in Sweden - on the contribution of bad housing to poor health in vulnerable populations

Background

Atopic disorders are a global concern. Studies in migrant populations can illuminate the interplay of genetic and environmental factors. Exposures related to bad housing (indoor dampness, mould growth, crowding etc.) are likely to play a role in how socioeconomic inequalities can turn into health disparities for disadvantaged populations. The sizable immigrant population living in very poor-quality housing in Malmö, Sweden, became the focus of a cross-sectional study.

Objective

To describe atopic disorders and sensitizations in a population living in substandard housing in Malmö, Sweden, with an emphasis on their relation to harmful exposures from the built environment.

Methods

Families were recruited via identification of any children with symptomatic airway afflictions from health care records, and also asymptomatic children from school lists. Interviewer-led health questionnaire data and data from self-reports about living conditions were obtained together with data from home inspections carried out by health communicators. Families underwent skin prick tests (SPT) against common aeroallergens.

Results

As could be expected from background demographic information, it turned out that we effectively studied an immigrant population inhabiting very precarious housing outside the center of Malmö. A total of 359 children from 130 families (total 650 participants) were included. Overall the prevalence of potentially harmful environmental exposures was high (signs of moisture or mould in more than 50% of apartments, indoor smoking in 37% of households). Atopic disorders were common among both adults and children. SPTs showed a spectrum of sensitizations consistent with unselected populations in Sweden. Paternal sensitization in the SPT was associated with higher risk of sensitization for offspring than maternal sensitization. Few statistically significant associations of atopic sensitization with studied environmental exposures were detected (for example objective signs of dampness /mould in bathrooms). There were marked discrepancies between asthma diagnoses obtained from the health records and parental reports of such diagnoses and treatment for their children.

Conclusions

The atopic burden in this selected immigrant population was high, and results point to unmet medical needs. Health care systems caring for such populations need to be aware of their specific health needs; comprehensive asthma and allergy care should include consideration of harmful environmental exposures, adhering to the precautionary principle.

Characterization of Stress in Low-Income, Inner-City Mothers of Children with Poorly Controlled Asthma

The goal of this longitudinal analysis was to characterize factors associated with the experience of life stress in low-income, inner-city mothers of minority children with high-risk asthma.Participants (n = 276) reported on family demographics, child asthma control and healthcare utilization, social support, contemporary life difficulties (housing, finances, violence exposure) measured by the validated Crisis in Family Systems scale, and daily stress. Latent growth curve modeling examined predictors of life stress across 12 months as a function of home and community difficulties, asthma-specific factors, and social support. Mothers were primarily single (73%), unemployed (55%), and living in extreme poverty with most (73%) reporting an annual family income <$20,000 (73%). The children were young (mean age = 5.59, SD = 2.17), African-American (96%), and had poorly controlled asthma (94%) at study enrollment. Higher daily stress was associated with financial difficulties, safety concerns in the home and community, and housing problems. Access to social support was consistently related to reduced stress. The only asthma-specific factor associated with life stress was healthcare utilization, with more emergency services for asthma related to higher daily stress. Findings underscore the clinical significance of assessing diverse home and community stressors and social support in low-income, inner-city caregivers of children with poorly controlled asthma.

Housing and Health of Kiribati Migrants Living in New Zealand

Settlement is a complex process of adjustment for migrants and refugees. Drawing on recent research on the settlement experiences of Kiribati migrants and their families living in New Zealand, this article examines the role of housing as an influencer of the settlement and health of Kiribati migrants. Using qualitative methodology, in-depth interviews were conducted with fourteen Kiribati migrants (eight women and six men) representing 91 family members about the key issues and events that shaped their settlement in New Zealand. The stories told by participants affirm the association between housing and health. The study serves as an important reminder that children bear a great cost from living in poorly insulated and damp housing, and adults bear the mental costs, including social isolation resulting from inadequate rental housing. Detailed information about how this migrant group entered the private rental housing market, by taking over the rental leases of other Kiribati migrants vacating their rental properties, indicated some of the unintended consequences related to a lack of incentives for landlords to make improvements. With the most vulnerable families most at risk from inadequate housing, this research concludes that there is a need for minimum housing standards to protect tenants.

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma-implications for home environmental intervention in asthma prevention and management

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

Removing asthma triggers and improving children's health: The Asthma Partnership Demonstration project

BACKGROUND

Studies have revealed the efficacy of home-based environmental interventions on reduction of asthma symptoms as a strategy for managing asthma in children. A focus on education and behavior change alone is generally too limited to reduce exposure to asthma triggers that exist because of adverse housing conditions.

OBJECTIVE

To demonstrate that housing conditions as a focus of a health intervention should be considered more widely as an effective means of addressing serious health problems such as asthma.

METHODS

Residences of 41 families of children identified with some of the highest rates of asthma-related hospital visits were assessed for the presence of asthma triggers.

RESULTS

The intervention had a positive effect on lessening the effect of the child's asthma on the family's lives and activities. Reductions in frequency of negative effects of children's asthma on sleeping, job or work around the house, and family activity plans, fewer worries or concerns about children getting enough sleep and performing normal daily activities, and fewer adverse effects of children's asthma medications were reported. Reduced use of asthma medication, medication applications, and health visits were noted. Households with return visits had 50% lower hospital bills for childhood asthma treatment.

CONCLUSION

Home environment conditions that lead to or exacerbate asthma may be reduced or eliminated by making minor repairs and introducing reasonable cleaning regimens that address sources of asthma triggers. This can produce greater awareness on the part of families about the presence of asthma triggers and motivate future action to address the conditions associated with these triggers.

Bronchial thermoplasty: implementing best practice in the era of cost containment

Increasing dependence on advanced technologies in the 21st century has created a dilemma between the practice and business of medicine. From information technology to robotic surgery, new technologies have expanded treatment possibilities and have potentially improved patient outcomes and safety. Simultaneously, their escalating costs limit access for certain patients and health care facilities. Nevertheless, medical decisions should not simply be based on cost. Input from physicians and other health care specialists as well as adherence to best practice position statements, are vital to implementing truly cost-effective strategies in medicine. Bronchial thermoplasty (BT), a US Food and Drug Administration approved bronchoscopy procedure in difficult-to-control persistent asthma, is a prime example of a new technology facing cost and implementation challenges. We discuss the specific indications and contraindications for BT and review recent real-world experiences that can provide the foundation for building a comprehensive asthma program that provides BT for difficult-to-control asthma patients who fail national guideline treatment recommendations after an adequate clinical trial of one. We also offer insight into the barriers to implementing a successful BT program and strategies for overcoming them.

Care transition interventions for children with asthma in the emergency department

The emergency department (ED) is a critical point of identification and treatment for some of the most high-risk children with asthma. This review summarizes the evidence regarding care transition interventions originating in the ED for children with uncontrolled asthma, with a focus on care coordination and self-management education. Although many interventions on care transition for pediatric asthma have been tested, only a few were actually conducted in the ED setting. Most of these targeted both care coordination and self-management education but ultimately did not improve attendance at follow-up appointments with primary care providers, improve asthma control, or reduce health care utilization. Conducting any ED-based intervention in the current environment is challenging because of the many demands on ED providers and staff, poor communication within and outside of the medical sector, and caregiver/patient burden. The evidence to date suggests that ED care transition interventions should consider expanding beyond the ED to bridge the multiple sectors children with asthma navigate, including health care settings, homes, schools, and community spaces. Patient-centered approaches may also be important to ensure adequate intervention design, enrollment, retention, and evaluation of outcomes important to children and their families.

Health Complaints Associated with Poor Rental Housing Conditions in Arkansas: The Only State without a Landlord's Implied Warranty of Habitability

Arkansas is the only U.S. state that does not have a landlord's implied warranty of habitability, meaning tenants have a requirement for maintaining their rental properties at certain habitability standards, but landlords are not legally required to contribute to those minimum health and safety standards. This project assessed the possibility that this lack of landlord responsibility affects tenants' perceived health. Using surveys and interviews, we collected self-reported data on the prevalence and description of problems faced by renters who needed household repairs from their landlords. Of almost 1,000 renters, one-third of them had experienced a problem with their landlord making needed repairs; and one-quarter of those had a health issue they attributed to their housing conditions. Common issues included problems with plumbing, heating, or cooling systems, and pest or rodent control. Reported health problems included elevated stress levels, breathing problems, headaches, high blood pressure, and bites or infections. Hispanic respondents and those with less than a high school education were both significantly more likely to report problems with their landlords not making repairs as requested. These data suggest that the lack of landlord requirements may negatively impact the condition of rental properties and, therefore, may negatively impact the health of Arkansas renters.

Breathe Easy at Home: A Qualitative Evaluation of a Pediatric Asthma Intervention

The Breathe Easy at Home Program enables clinicians to refer asthmatic patients to Boston Inspectional Services Department (ISD) if they suspect housing conditions trigger symptoms. The authors conducted one-on-one interviews with clinicians (n = 10) who referred patients, and focus groups with inspectors from the ISD (n = 9) and a variety of stakeholders (n = 13), to gain insight into program function and implementation. Clinician interviews revealed inconsistencies in enrollment approaches, dissatisfaction with the web-based system, and patient follow-up difficulties. Inspectors identified barriers to working effectively with residents and landlords, and the stakeholder focus group highlighted successes of an unusual institutional collaboration. Interviews and focus groups identified strong and personal rapport between clinicians, inspectors, and patients as key to program retention, and that participating families required additional support throughout the process. Despite recommendations for improvement in program implementation, clinicians, inspectors, and stakeholders felt that the program overall improved both the home environment and asthma outcomes.

Moving into green healthy housing

BACKGROUND

Green building systems have proliferated but health outcomes and associated costs and benefits remain poorly understood.

OBJECTIVE

To compare health before and after families moved into new green healthy housing with a control group in traditionally repaired housing.

DESIGN AND SETTING

Mixed methods study in 3 Chicago housing developments.

PARTICIPANTS

Public housing and low-income subsidized households (n = 325 apartments with 803 individuals).

MAIN OUTCOME MEASURES

Self-reported health status, visual assessment of housing condition, indoor air sampling, and Medicaid expenditure and diagnostic data. Medicaid expenditures and International Classification of Diseases, Ninth Revision codes were modeled using a generalized linear model with γ distribution and log-link.

RESULTS

Housing conditions and self-reported physical and mental health improved significantly in the green healthy housing study group compared with both the control group and the dilapidated public housing from which the residents moved, as did hay fever, headaches, sinusitis, angina, and respiratory allergy. Asthma severity measured by self-reported lost school/work days, disturbed sleep, and symptoms improved significantly, as did sadness, nervousness, restlessness, and child behavior. Medicaid data in this exploratory study were inconclusive and inconsistent with self-reported health outcomes and visual assessment data on housing quality but hold promise for future investigation. Possible sources of bias in the Medicaid data include older age in the study group, changes in Medicaid eligibility over time, controlling for Medicaid costs in an urban area, and the increased stress associated with moving, even if the move is into better housing.

CONCLUSION

The mixed method approach employed here describes the complex relationships among self-reported health, housing conditions, environmental measures, and clinical data. Housing conditions and self-reported physical and mental health improved in green healthy housing. Health care cost savings in Medicaid due to improved housing could not be quantified here but hold promise for future investigations with larger cohorts over a longer follow-up period.

State-level medical and absenteeism cost of asthma in the United States

OBJECTIVE

For medically treated asthma, we estimated prevalence, medical and absenteeism costs, and projected medical costs from 2015 to 2020 for the entire population and separately for children in the 50 US states and District of Columbia (DC) using the most recently available data.

METHODS

We used multiple data sources, including the Medical Expenditure Panel Survey, U.S. Census Bureau, Kaiser Family Foundation, Medical Statistical Information System, and Current Population Survey. We used a two-part regression model to estimate annual medical costs of asthma and a negative binomial model to estimate annual school and work days missed due to asthma.

RESULTS

Per capita medical costs of asthma ranged from $1,860 (Mississippi) to $2,514 (Michigan). Total medical costs of asthma ranged from $60.7 million (Wyoming) to $3.4 billion (California). Medicaid costs ranged from $4.1 million (Wyoming) to $566.8 million (California), Medicare from $5.9 million (DC) to $446.6 million (California), and costs paid by private insurers ranged from $27.2 million (DC) to $1.4 billion (California). Total annual school and work days lost due to asthma ranged from 22.4 thousand (Wyoming) to 1.5 million days (California) and absenteeism costs ranged from $4.4 million (Wyoming) to $345 million (California). Projected increase in medical costs from 2015 to 2020 ranged from 9% (DC) to 34% (Arizona).

CONCLUSION

Medical and absenteeism costs of asthma represent a significant economic burden for states and these costs are expected to rise. Our study results emphasize the urgency for strategies to strengthen state level efforts to prevent and control asthma attacks.

Asthma in Children With Comorbid Obesity: Intervention Development in a High-Risk Urban Community

This article describes formative work conducted to inform design of an intervention targeting asthma control in overweight/obese children. Using a PRECEDE-PROCEED framework and a community-based participatory research approach, investigators conducted key informant interviews and focus groups in a low-income urban community. Key informants (N = 18) represented schools and community agencies. Focus groups were conducted with caregivers (4 groups, N = 31) and children (3 groups, N = 30). Focus group participants were low-income and African American, Puerto Rican, or Mexican. Children were age 5 to 12 years and overweight or obese with a diagnosis of asthma; caregivers had a child meeting these criteria. A range of issues competed with families' day-to-day prioritization and management of asthma, with social limitations reported as the most important issue. Many school-level and individual-level barriers were described. Caregivers and children drew strong connections between asthma and obesity and described their need to comanage these conditions. The connection between the diseases was not as obvious for the key informants, many of whom control the services families receive. These results led to an understanding of key targets and components that are needed for a multilevel community-based intervention to be relevant and appropriate in low-income children with both asthma and obesity.

Time-Based Measurement of Personal Mite Allergen Bioaerosol Exposure over 24 Hour Periods

Allergic diseases such as asthma and rhinitis are common in many countries. Globally the most common allergen associated with symptoms is produced by house dust mites. Although the bed has often been cited as the main site of exposure to mite allergens, surprisingly this has not yet been directly established by measurement due to a lack of suitable methods. Here we report on the development of novel methods to determine the pattern of personal exposure to mite allergen bioaerosols over 24-hour periods and applied this in a small field study using 10 normal adults. Air was sampled using a miniature time-based air-sampler of in-house design located close to the breathing zone of the participants, co-located with a miniature time-lapse camera. Airborne particles, drawn into the sampler at 2L/min via a narrow slot, were impacted onto the peripheral surface of a disk mounted on the hour-hand of either a 12 or 24 hour clock motor. The impaction surface was either an electret cloth, or an adhesive film; both novel for these purposes. Following a review of the time-lapse images, disks were post-hoc cut into subsamples corresponding to eight predetermined categories of indoor or outdoor location, extracted and analysed for mite allergen Der p 1 by an amplified ELISA. Allergen was detected in 57.2% of the total of 353 subsamples collected during 20 days of sampling. Exposure patterns varied over time. Higher concentrations of airborne mite allergen were typically measured in samples collected from domestic locations in the day and evening. Indoor domestic Der p 1 exposures accounted for 59.5% of total exposure, whereas total in-bed-asleep exposure, which varied 80 fold between individuals, accounted overall for 9.85% of total exposure, suggesting beds are not often the main site of exposure. This study establishes the feasibility of novel methods for determining the time-geography of personal exposure to many bioaerosols and identifies new areas for future technical development and clinical applications.

Health Benefits of Green Public Housing: Associations With Asthma Morbidity and Building-Related Symptoms

OBJECTIVES

We examined associations of several health outcomes with green and conventional low-income housing, where the prevalence of morbidities and environmental pollutants is elevated.

METHODS

We used questionnaires and a visual inspection to compare sick building syndrome (SBS) symptoms and asthma-related morbidity among residents in multifamily units in Boston, Massachusetts, between March 2012 and May 2013. Follow-up was approximately 1 year later.

RESULTS

Adults living in green units reported 1.35 (95% confidence interval [CI] = 0.66, 2.05) fewer SBS symptoms than those living in conventional (control) homes (P < .001). Furthermore, asthmatic children living in green homes experienced substantially lower risk of asthma symptoms (odds ratio [OR] = 0.34; 95% CI = 0.12, 1.00), asthma attacks (OR = 0.31; 95% CI = 0.11, 0.88), hospital visits (OR = 0.24; 95% CI = 0.06, 0.88), and asthma-related school absences (OR = 0.21; 95% CI = 0.06, 0.74) than children living in conventional public housing.

CONCLUSIONS

Participants living in green homes had improved health outcomes, which remained consistent over the study period. Green housing may provide a significant value in resource-poor settings where green construction or renovation could simultaneously reduce harmful indoor exposures, promote resident health, and reduce operational costs.

Impacting Environmental and Public Health through the Use of Dual Targeted and Tailored Asthma Educational Interventions

Home-based asthma environmental education for parents of asthmatic children is needed since many health professionals lack the time to offer it. However, developing targeted and tailored education is important in order to address the individual needs of participants. This nonrandomized longitudinal study examined knowledge on asthma with an Asthma and Healthy Homes educational intervention training offered to parents of children from low income families who reside in the Rio Grande Valley of Texas. Eighty-nine parents received the training and pre- and posttest surveys were used to measure knowledge outcomes. A standardized assessment on asthma triggers was used to identify the different triggers each child was exposed to, and a follow-up survey was conducted 6 months after the educational intervention to identify how many parents reported household and behavior changes as a result of the training. Results showed significant changes in behavior by participants as a result of the training received. This study suggests that these behavioral changes are attributed to the dual "targeted" and "tailored" educational interventions delivered to parents which resulted in a greater understanding of how to manage asthma by eliminating asthma triggers in their respective homes.

Mexican-American caregivers' perceptions about asthma management: a photovoice study

OBJECTIVE

The purpose of this study is to report how photovoice was used to (1) ascertain Mexican-American caregiver perspectives about asthma management, and (2) engage caregivers in dissemination.

METHODS

Eleven Mexican-American caregivers of children with asthma were recruited and given cameras to photograph what helped or hindered their ability to care for their child. Participants prioritized which images to share, discussed the images with the group, and wrote accompanying titles and captions in four photovoice sessions. Sessions were in Spanish and occurred in a community setting. Participants presented their work to peers and community members. Identified issues were subsequently categorized by investigators according to the four components of asthma care.

RESULTS

Participants prioritized 32 phototexts, the majority of which (n = 20, 63%) reflected activities associated with environmental control. Caregivers highlighted asthma triggers, and suggested ways to maintain indoor air quality (IAQ) through home cleaning. The need for policies that enforce smoking bans in shared housing and public places was identified as an important strategy to improve outdoor air quality. "Education for a Partnership in Asthma Care" was represented in six (19%) phototexts. Five phototexts (16%) represented "Assessment and Monitoring". Only one phototext (3.13%) primarily represented "Medications".

CONCLUSIONS

Results support the need for active partnerships between caregivers and providers. Photographs can serve as the basis for reciprocal education between patient and provider, especially in the area of environmental triggers. Provider visits should include assessment, strategies and resources to maximize IAQ. Photovoice facilitates caregivers' ability to advocate for improved asthma management and health equity.

Lifestyle domains as determinants of wheeze prevalence in urban and rural schoolchildren in Ecuador: cross sectional analysis

BACKGROUND

The acquisition of a modern lifestyle may explain variations in asthma prevalence between urban and rural areas in developing countries. However, the effects of lifestyle on asthma have been investigated as individual factors with little consideration given to the effects of lifestyle as a set of attributes. The aim of the present study was to identify modern lifestyle domains and assess how these domains might explain wheeze prevalence in urban and rural areas.

METHODS

We analysed data from cross-sectional studies of urban and rural schoolchildren in Esmeraldas Province, Ecuador. Variables were grouped as indicators of socioeconomic factors, sedentarism, agricultural activities and household characteristics to represent the main lifestyle features of the study population. We used multiple correspondence analyses to identify common lifestyle domains and cluster analysis to allocate children to each domain. We evaluated associations between domains and recent wheeze by logistic regression.

RESULTS

We identified 2-3 lifestyle domains for each variable group. Although wheeze prevalence was similar in urban (9.4%) and rural (10.3%) schoolchildren, lifestyle domains presented clear associations with wheeze prevalence. Domains relating to home infrastructure (termed transitional, rudimentary, and basic urban) had the strongest overall effect on wheeze prevalence in both urban (rudimentary vs. basic urban, OR = 2.38, 95% CI 1.12-5.05, p = 0.024) and rural areas (transitional vs. basic urban, OR = 2.02, 95% CI 1.1-3.73, p = 0.024; rudimentary vs. basic urban, OR = 1.88, 95% CI 1.02-3.47, p = 0.043). A high level of sedentarism was associated with wheeze in the rural areas only (OR = 1.64, 95% CI 1.23-2.18, p = 0.001).

CONCLUSIONS

We identified lifestyle domains associated with wheeze prevalence, particularly living in substandard housing and a high level of sedentarism. Such factors could be modified through programmes of improved housing and education. The use of lifestyle domains provides an alternative methodology for the evaluation of variations in wheeze prevalence in populations with different levels of development.

Effectiveness of a promotora home visitation program for underserved Hispanic children with asthma

OBJECTIVE

Retention in a mobile asthma clinic, the Breathmobile™, of ≥3 visits has previously been shown to be essential for attaining asthma control in underserved children. The objective of this study in primarily Hispanic-American children was to determine the difference in retention between those seen in the Breathmobile™ compared to those receiving an additional promotora-based home visit (HV).

METHODS

Children with asthma in the Breathmobile™ program were evaluated for asthma status and aeroallergen sensitivity. Indication for HV included poor asthma control, educational and environmental control needs. An initial visit consisted of environmental assessment as well as a 3-h interactive educational session covering asthma basics. A follow-up visit 1 month later assessed implementation. The primary outcome measure of retention was ≥6 months in the Breathmobile™ program.

RESULTS

Of the 1007 asthmatic children seen between April 2002 and June of 2005, 136 received HV. These children showed significantly greater retention compared to those without HV with a median number of visits (5 visits versus 2 visits), ≥3 Breathmobile™ visits (86.0% versus 38.8%), median number of days in the program (299 versus 63 days) and percentage of patients in the program ≥6 months (67.8% versus 31.3%) p < 0.001. HV and asthma severity were each independent predictors of retention.

CONCLUSIONS

The addition of a promotora HV program proved effective in providing greater retention in the Breathmobile™ program essential for asthma control. Randomized clinical trials will be needed to show the impact on health care utilization and asthma control.

Associations of neighborhood concentrated poverty, neighborhood racial/ethnic composition, and indoor allergen exposures: a cross-sectional analysis of los angeles households, 2006-2008

Although racial/ethnic, socioeconomic, and neighborhood factors have been linked to asthma, and the association between indoor allergens and asthma is well documented, few studies have examined the relationship between these factors and indoor allergens. We examined the frequency of reported indoor allergens and differences by racial/ethnic, socioeconomic, and neighborhood characteristics among a diverse sample of Los Angeles households. Multilevel logistic regression models were used to analyze the data from 723 households from wave 2 of the Los Angeles Family and Neighborhood Survey. The reported presence of rats, mice, cockroaches, mold, pets, and tobacco smoke were the primary outcomes of interest. Hispanic and Asian households had a nearly threefold increase in the odds of reporting cockroaches compared to non-Hispanic Whites (OR, 2.85; 95 % CI 1.38-5.88 and OR, 2.62; 95 % CI 1.02-6.73, respectively) even after adjusting for socioeconomic factors. Primary caregivers who had obtained a high school degree were significantly less likely to report the presence of mice and cockroaches compared to primary caregivers with less than a high school degree (OR, 0.19; 95 % CI 0.08-0.46 and OR, 0.39; 95 % CI 0.23-0.68, respectively). Primary caregivers with more than a high school degree were also less likely to report the presence of rats, mice, and cockroaches within their households, compared to those with less than a high school degree. Compared to renters, home owners were less likely to report the presence of mice, cockroaches, and mold within their households. At the neighborhood level, households located within neighborhoods of high concentrated poverty (where the average poverty rate is at least 50 %) were more likely to report the presence of mice and cockroaches compared to households in low concentrated poverty neighborhoods (average poverty rate is 10 % or less), after adjusting for individual race/ethnicity and socioeconomic characteristics. Our study found evidence in support of neighborhood-level racial/ethnic and socioeconomic influences on indoor allergen exposure, above and beyond individual factors. Future studies should continue to explore individual and neighborhood-level racial/ethnic and socioeconomic differences in household allergen exposures across diverse contexts.

Determinants of asthma control among children in Saudi Arabia

OBJECTIVE

Asthma is the most common chronic disease among children. Uncontrolled asthma may considerably decrease the quality of life for patients and their families. Our objective was to identify possible risk factors for poor asthma control in children.

METHODS

A cross-sectional study was conducted among children with asthma aged 4-11 years who attended a pediatric clinic for follow-up visits at one of the major teaching hospitals in Riyadh, Saudi Arabia. Asthma control status was measured by the childhood asthma control test. Multiple logistic regression analysis was performed to explore the relationships between the outcome and exposure variables.

RESULTS

Uncontrolled asthma was present in 89 out of 158 children (59.3%). Asthma control improved with the number of siblings. Control improved by 69% with two or three siblings (OR = 0.31, 95% CI = 0.10-0.96) and by 87% with four or more siblings (OR = 0.13, 95% CI = 0.04-0.48). Similarly, asthma control improved with an increased asthma knowledge of the caregiver (OR = 0.87, 95% CI = 0.81-0.93). Household incomes less than SAR 15 000 and sharing a bedroom increased the odds of having uncontrolled asthma by 2.30 (95% CI = 1.02-5.21) and 3.33 (95% CI = 1.33-8.35), respectively.

CONCLUSIONS

In addition to knowledge, socioeconomic factors, such as family income, household crowding, and the number of siblings are associated with asthma control among children in Saudi Arabia. Further research is needed to investigate the role of these factors.

Transitioning from health disparities to a health equity research agenda: the time is now

Health disparities are real. The evidence base is large and irrefutable. As such, the time is now to shift the research emphasis away from solely documenting the pervasiveness of the health disparities problem and begin focusing on health equity, the highest level of health possible. The focus on health equity research will require investigators to propose projects that develop and evaluate evidence-based solutions to health differences that are driven largely by social, economic, and environmental factors. This article highlights ongoing research and programmatic efforts underway at the National Institutes of Health that hold promise for advancing population health and improving health equity.

Housing and child health

The connection between housing and health is well established. Physical, chemical, and biological aspects of the child's home, such as cleanliness, moisture, pests, noise, accessibility, injury risks, and other forms of housing environmental quality, all have the potential to influence multiple aspects of the health and development of children. Basic sanitation, reduced household crowding, other improvements in housing and expanded, and improved housing regulations have led to advances in children's health. For example, lead poisoning prevention policies have profoundly reduced childhood lead exposure in the United States. This and many other successes highlight the health benefits for families, particularly children, by targeting interventions that reduce or eliminate harmful exposures in the home. Additionally, parental mental health problems, food insecurity, domestic violence, and the presence of guns in children's homes all are largely experienced by children in their homes, which are not as yet considered part of the Healthy Homes agenda. There is a large movement and now a regulatory structure being put in place for healthy housing, which is becoming closely wedded with environmental health, public health, and the practice of pediatrics. The importance of homes in children's lives, history of healthy homes, asthma, and exposures to lead, carbon monoxide, secondhand/thirdhand smoke, radon, allergy triggers is discussed, as well as how changes in ambient temperature, increased humidity, poor ventilation, water quality, infectious diseases, housing structure, guns, electronic media, family structure, and domestic violence all affect children's health.

Impact of the environment on asthma control

Asthma is a complex condition that requires individualized interventions. The purpose of this article is to describe the relationship between the physical and social environments with asthma symptoms, present evidence that supports environmental interventions in asthma control and the implications for asthma management. There is evidence that indoor and outdoor allergens relate to asthma morbidity. Knowledge about which environmental exposures present risk is essential because many of these exposures can be modified, reduced, or eliminated. The community health nurse should provide care relative to the client's indoor and outdoor environment and existing allergens.

Home/social environment and asthma profiles in a vulnerable community from Caracas: lessons for urban Venezuela?

BACKGROUND

Asthma is a significant public health problem in Venezuela affecting the predominantly urban and poor majority of the population. Information regarding home and the social environment, key elements in asthma, is found to be deficient in these deprived socioeconomic sectors. This study was carried out to depict a life with asthma in this context which has been served over the years by a National Asthma Control Program.

METHODS

A survey of families residing in a socioeconomically deprived community of Caracas was carried out with the assumption that this community reflects the image of a life with asthma emanating from our deprived urban areas. Home physical settings were inspected for the following items: moldy walls, floors, ceilings, windows, sewage, garbage disposal, running water, plumbing, electricity, telephone, construction debris, furniture, bathrooms, food storage, and home appliances. In addition, we also gathered information regarding smoking habits, fumes exposure, pets and/or animals, and sighting of roaches and/or rodents. The presence of people with asthma was observed and their status of control was assessed through the asthma control test (ACT). Comparisons were made between families with asthmatics and those without asthmatics.

RESULTS

Randomly, 242 of 750 families (32.26%) were surveyed, with "head of family" providing information (75.6%) on most occasions. No significant association was found with respect to the previously explored items in those families with or without the presence of asthmatics. Medically diagnosed asthma was found in 14.91%, with ACT scores of <19 points in two-thirds of these adults and asthmatic children. Asthmatics reported symptoms occurring mostly during the night and an almost exclusive use of rescue medications. Families provided most treatments and children preferred to use the oral route for control medications. Significant work and school absenteeism were detected in more than 50% of these asthmatics.

CONCLUSIONS

No physical home environmental/risk factors turned out to be significantly associated with families reporting the presence of asthmatics. The high impact of asthma found in this Caracas slum underscores the realities of Venezuela's impoverished urban majority. To properly address this important challenge, our National Asthma Control Program needs to be reassessed.