Effect of a home intervention program on pediatric asthma in an environmental justice community

Effectiveness of Asthma Home Management Manual and Low-Cost Air Filter on Quality of Life Among Asthma Adults: A 3-Arm Randomized Controlled Trial

Background

Asthma affects the quality of life (QoL) of millions of people worldwide. Effective control is paramount to a decline in prevalence and severity. To address this, we aimed to investigate the effectiveness of an asthma home management manual and low-cost air filter in improving resource-limited settings.

Patients and Methods

This randomized controlled trial was conducted between March to July 2022. The participants were 18-55 years old outpatient with asthmatic patients. A total of 114 participants were recruited and randomly assigned to three groups: home management only, home management and air filtering, and control. Validated measurement tools were applied, and the Wilcoxon test was used to evaluate changes in QoL.

Results

Asthma burden was found in at least one-third of participants in each group. At baseline, there was no difference in mAQLQ scores among participants in all group allocations (p-value > 0.05), and the air filter group had an increase in the total mAQLQ score (p-value = 0.044) and post-intervention activity quality of life (p-value = 0.002). The environmental quality of life increased post-intervention (p-value = 0.004) and remained higher after four weeks of follow-up compared to baseline (p-value = 0.041) in the home management group participants.

Conclusion

The findings indicate that the enforcement of a home management manual and the application of low-cost filters in air circulation systems offer advantages in improving the quality of life of patients with moderate and mild asthma.

Social Risk Interventions and Health Care Utilization for Pediatric Asthma: A Systematic Review and Meta-analysis

IMPORTANCE

Social determinants of health (SDOH) correlate with pediatric asthma morbidity, yet whether interventions addressing social risks are associated with asthma outcomes among children is unclear.

OBJECTIVE

To catalog asthma interventions by the social risks they address and synthesize their associations with asthma-related emergency department (ED) visits and hospitalizations among children.

DATA SOURCES

PubMed, Scopus, PsycINFO, SocINDEX, CINAHL, and references of included full-text articles were searched from January 1, 2008, to June 16, 2021.

STUDY SELECTION

Included articles were US-based studies evaluating the associations of interventions addressing 1 or more social risks with asthma-related ED visits and hospitalizations among children. The systematic review included 38 of the original 641 identified articles (6%), and the meta-analysis included 19 articles (3%).

DATA EXTRACTION AND SYNTHESIS

Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. The SDOH intervention clusters were identified by grouping studies according to the social risks they addressed, using the Healthy People 2020 SDOH framework. Random-effects models created pooled risk ratios (RRs) as the effect estimates.

MAIN OUTCOMES AND MEASURES

Patients with ED visits or hospitalizations were the primary outcomes. Subgroup analyses were conducted by an SDOH intervention cluster. Sensitivity analyses were conducted for each, removing outlier studies and studies failing to meet the minimum quality threshold.

RESULTS

In total, 38 studies were included in the systematic review, with 19 of these studies providing data for the meta-analysis (5441 participants). All interventions addressed 1 or more of the health, environment, and community domains; no interventions focused on the economy or education domains. In the primary analysis, social risk interventions were associated with decreased ED visits (RR, 0.68; 95% CI, 0.57-0.81; I2 = 70%) and hospitalizations (RR, 0.50; 95% CI, 0.37-0.68; I2 = 69%). In subgroup analyses, the health, environment, and community intervention cluster produced the lowest RR for ED visits (RR, 0.53; 95% CI, 0.44-0.64; I2 = 50%) and for hospitalizations (RR, 0.33; 95% CI, 0.20-0.55; I2 = 71%) compared with other intervention clusters. Sensitivity analyses did not alter primary or subgroup effect estimates.

CONCLUSIONS AND RELEVANCE

The results of this systematic review and meta-analysis indicate that social risk interventions are associated with decreased asthma-related ED visits and hospitalizations among children. These findings suggest that addressing social risks may be a crucial component of pediatric asthma care to improve health outcomes.

Community-based interventions for childhood asthma using comprehensive approaches: a systematic review and meta-analysis

Objective

We conducted a systematic review and meta-analysis to determine the effectiveness of comprehensive community-based interventions with ≥ 2 components in improving asthma outcomes in children.

Methods

A systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Cochrane Library and hand search of reference collections were conducted to identify any research articles published in English between 2000 and 2019. All studies reporting community-based asthma interventions with ≥ 2 components (e.g., asthma self-management education, home environmental assessment or care coordination etc.) for children aged ≤ 18 years were included. Meta-analyses were performed using random-effects model to estimate pooled odds ratio (OR) with 95% confidence intervals (CIs).

Results

Of the 2352 studies identified, 21 studies were included in the final analysis: 19 pre-post interventions, one randomised controlled trial (RCT) and one retrospective study. Comprehensive asthma programs with multicomponent interventions were associated with significant reduction in asthma-related Emergency Department (ED) visits (OR = 0.26; 95% CI 0.20–0.35), hospitalizations (OR = 0.24; 95% CI 0.15–0.38), number of days (mean difference = − 2.58; 95% CI − 3.00 to − 2.17) and nights with asthma symptoms (mean difference = − 2.14; 95% CI − 2.94 to − 1.34), use of short-acting asthma medications/bronchodilators (BD) (OR = 0.28; 95% CI 0.16–0.51), and increase use of asthma action plan (AAP) (OR = 8.87; 95% CI 3.85–20.45).

Conclusion

Community-based asthma care using more comprehensive approaches may improve childhood asthma management and reduce asthma related health care utilization.

Assessment of a University-Based Outpatient Asthma Education Program for Children

INTRODUCTION

To assess the effect of a pediatric asthma intervention program on reducing asthma morbidity.

METHODS

Study eligibility criteria included aged less than 18 years and at least two office visits for asthma in the previous year. Patients were randomly assigned to either the control or intent to intervene group. The intervention included home visits and education on the basic pathophysiology of asthma, self-management techniques, modification of asthma triggers, and proper use of asthma medications by a certified nurse educator.

RESULTS

Using simple randomization, 901 eligible pediatric patients with asthma were assigned; 458 to the control and 443 to the intent to intervene group. Of the 443 patients randomized to the intent to intervene group, 271 received the asthma education intervention. Most of the remaining 172 patients in the intent to intervene group did not receive the intervention owing to not having an appointment during the study period. Only 27 families allowed a home visit. After controlling for the difference in sex, children in the intent to intervene group had significantly less total clinic visits (incidence rate ratio [IRR] = 0.53, p < .01), and steroid bursts (IRR = 0.47, p < .01) than controls.

DISCUSSION

The implementation of a pediatric asthma education program decreased both the total clinic visits and the need for steroid bursts consistent with better asthma control. We demonstrated the benefit of a dedicated asthma educator in university-based community practice and recommend this intervention be considered a standard of care for children with asthma in all health-care settings.

Effects of the home-based educational intervention on health outcomes among primarily Hispanic children with asthma: a quasi-experimental study

BACKGROUND

Childhood asthma is a significant health issue with 8.3% prevalence in the U.S. Its prevalence is particularly higher among low-income communities in the Texas-Mexico border region, as they often lack access to clinical care and health insurance. This study examines the impact of a home-based education led by Community Health Workers (CHWs) on health outcomes for asthmatic, predominantly Hispanic children in these communities.

METHODS

The study was a quasi-experimental design to learn the effectiveness of the asthma home-based education by comparing changes of health outcomes between baseline and follow-up of intervention and control groups. This study enrolled 290 participants, consisting of 130 in the intervention group and 160 in the control group. The educational intervention led by the CHWs referenced the Asthma and Healthy Homes curriculum and contents of the Seven Principles of Healthy Homes. The multiple linear regression analysis was conducted to estimate the associations between the intervention and each health outcome.

RESULTS

When comparing the intervention group with the control group, the intervention group showed a significantly greater decrease in asthma attacks than the control group (p = 0.049). Although all of the five Children's Health Survey for Asthma (CHSA) scores showed significant improvements between baseline and follow-up in both groups, we found that increases of CHSA scores in the intervention group were higher than the control group except for emotional health of children (EC) score. The multiple linear regression models demonstrated that the mean changes in asthma attacks (p = 0.036) and emotional health of families (EF) score (p = 0.038) were significantly better in the intervention group than the control group, adjusting for children's age of diagnosis, household income, use of steroids, family history of allergy, and type of insurance.

CONCLUSIONS

This study concluded that the home-based education by CHWs effectively improve health outcomes among children in communities lacking access to medical resources. The findings suggest the importance of the home-based education program in promoting emotional and medical care for children and their families in low-income communities like those in the Texas-Mexico border region.

Environmental justice screening tools: Implications for nursing

Environmental justice (EJ) means socially and economically disadvantaged communities and citizens are entitled to an equally clean environment and resources to enjoy. EJ communities are mostly located close to polluters such as Superfund sites, coal-fired power plants and landfills and are more likely to be exposed to higher levels of environmental hazards than the U.S. population on average. It is often a difficult task to identify EJ communities and the environmental hazards in the communities without using specific EJ screening tools. Therefore, the goal of this manuscript is to introduce public health nurses to map-based EJ screening tools. This will help public health nurses to identify EJ communities and take appropriate actions. Public Health Nurses can also use other relevant web sites, such as the U.S. Environmental Protection Agency (EPA), National Institute of Environmental Health Sciences (NIEHS) and Toxicology Data Network (TOXNET) as resources concerning potential health effects of pollutants. Using the provided tools in this paper, nurses should be able to identify EJ communities and be united to recognize barriers of EJ communities and become promoters for EJ advocacy in practice, leadership and education.

Working with an environmental justice community: Nurse observation, assessment, and intervention

Environmental justice (EJ) is the concept that all people and communities, regardless of their race and socioeconomic status, are entitled to enjoy an equally clean environment and resources. Communities where residents face environmental injustice and a higher risk of being exposed to environmental hazards due to their race, ethnicity, and socioeconomic status are called EJ communities. The purpose of this manuscript is to provide an example of nurses' involvement in observation, assessment, and intervention of an EJ community using a community-based participatory research (CBPR) model. Utilizing a multistage CBPR approach along with a mixed methods design, the project was carried out in three stages. Within the three stages, we conducted a thorough observation of the community, identified possible environmental issues, and collected health data and drinking water samples. Citizens' complaints included coal ash, failed sewer system, health issues, including kidney disorders and neuropathy. Drinking water samples (n = 59) showed lead levels higher than the health limits in 10.4% of samples. We intervened based on our short-term goal, reducing citizens' exposure to lead by education, and our long-term goal, reducing disparities, and exposures. We recommend that nurses increase their knowledge about EJ communities and environmental exposures and their health effects and be advocates for EJ communities.

An Evaluation of a State-Funded Healthy Homes Intervention on Asthma Outcomes in Adults and Children

CONTEXT

Reducing exposure to environmental triggers is a critical part of asthma management.

OBJECTIVE

To evaluate the impact of a healthy homes intervention on asthma outcomes and assess the impact of different targeting strategies.

SETTING

The New York State (NYS) Healthy Neighborhoods Program (HNP) operates in select communities with a higher burden of housing-related illness and associated risk factors.

PARTICIPANTS

Residents with asthma were recruited through 3 mechanisms: door-to-door canvassing (CANVASSED), 752 residents in 457 dwellings; referrals from community partners (REFERRED), 573 residents in 307 dwellings; referrals of Medicaid enrollees with poorly controlled asthma (TARGETED), 140 residents in 140 dwellings.

INTERVENTION

The NYS HNP provides visual assessments and low-cost interventions to identify and address asthma triggers and trigger-promoting conditions in the home environment. Conditions are reassessed during a revisit conducted 3 to 6 months after the initial visit.

MAIN OUTCOME MEASURE(S)

The analysis compares improvements across the 3 groups for measures of asthma self-management, health care access, morbidity, and environmental conditions. An asthma trigger score characterizing the extent of multiple triggers in a dwelling was also calculated.

RESULTS

Among 1465 adults and children, there were significant improvements in environmental conditions and self-reported self-management, health care access, and asthma morbidity outcomes for each group. The improvement was greatest in the TARGETED group for most outcomes, but selected measures of self-management and health care access were greater in the other groups. The mean improvement was significantly greater in the TARGETED group.

CONCLUSION

Targeting the intervention to people with poorly controlled asthma maximizes improvements in trigger avoidance and asthma morbidity; however, other recruitment strategies are effective for impacting endpoints related to health care access and self-management. This evaluation demonstrates that a low-intensity home-based environmental intervention is effective as well as practical and feasible. Health care payers, state and local health departments, and others should consider investing in these home-based services as part of a comprehensive asthma care package.

Health care access, concentrated poverty, and pediatric asthma hospital care use in California's San Joaquin Valley: A multilevel approach

BACKGROUND

California's San Joaquin Valley is a region with a history of poverty, low health care access, and high rates of pediatric asthma. It is important to understand the potential barriers to care that challenge vulnerable populations.

OBJECTIVE

The objective was to describe pediatric asthma-related utilization patterns in the emergency department (ED) and hospital by insurance coverage as well as to identify contributing individual-level indicators (age, sex, race/ethnicity, and insurance coverage) and neighborhood-level indicators of health care access.

METHODS

This was a retrospective study based on secondary data from California hospital and ED records 2007-2012. Children who used services for asthma-related conditions, were aged 0-14 years, Hispanic or non-Hispanic white, and resided in the San Joaquin Valley were included in the analysis. Poisson multilevel modeling was used to control for individual- and neighborhood-level factors.

RESULTS

The effect of insurance coverage on asthma ED visits and hospitalizations was modified by the neighborhood-level percentage of concentrated poverty (RR = 1.01, 95% CI = 1.01-1.02; RR = 1.03, 95% CI = 1.02-1.04, respectively). The effect of insurance coverage on asthma hospitalizations was completely explained by the neighborhood-level percentage of concentrated poverty.

CONCLUSIONS

Observed effects of insurance coverage on hospital care use were significantly modified by neighborhood-level measures of health care access and concentrated poverty. This suggests not only an overall greater risk for poor children on Medi-Cal, but also a greater vulnerability or response to neighborhood social factors such as socioeconomic status, community cohesiveness, crime, and racial/ethnic segregation.

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.

Asthma Disparity Photovoice: The Discourses of Black Adolescent and Public Health Policymakers

BACKGROUND

Policies in U.S. public schools that address asthma management for Black adolescents may not sufficiently transform sociocultural determinants of disparities. A critical analysis of public health policy maker and adolescent discourses on asthma management using an ecological framework could inform policy development. This study describes the discourses of asthma management disparities of school and other public health policymakers and Black adolescents with asthma during a statewide asthma planning activity.

METHOD

I conducted a qualitative critical discourse analysis on transcripts and phototexts from a photovoice project with Black adolescents with asthma (n = 19), an asthma-planning meeting with school and public health policymakers (n = 12), and an observation of a photovoice dissemination event that included the same adolescents and policymakers.

RESULTS

Policymakers did not discuss sociocultural discourses concerning asthma management disparities such as racism and discrimination, but the adolescents did. The only shared discourses between adolescents and policymakers were on the management of indoor environments, health care quality, inadequate housing, and outdoor air pollution.

CONCLUSIONS

Including Black adolescents in policymaking activities concerning asthma management disparities furthers the identification of differing and shared discourses. School policies should include multilevel strategies that address structural inequities. Photovoice presents an opportunity for including the voice of marginalized youth in policy-planning processes.

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.

Inner-city asthma: special considerations for management

PURPOSE OF REVIEW

Asthma is prevalent in inner-city populations, exhibiting significant morbidity and mortality. This review focuses on the consequential findings of recent literature, providing insight into onset of asthma, complicating factors, prediction of exacerbations, and novel treatment strategies.

RECENT FINDINGS

Analyses of environmental influence on inner-city children demonstrated novel interactions, implicating potentially protective benefits from early life exposures to pests and pets and isolating detrimental effects of air pollution on asthma morbidity. Through detailed characterization of inner-city asthmatics, predictors of seasonal exacerbations surfaced. Focused, season-specific treatment of inner-city asthmatics with omalizumab identified those most likely to benefit from season-tailored therapy. Comparative studies of urban and rural populations revealed that race and household income, rather than location of residence, impose the greatest risk for increased asthma prevalence and morbidity.

SUMMARY

Challenging previously conceived exposure-disease relationships, recent literature has elucidated new avenues in the complex interplay between immunologically active exposures and their effects on inner-city asthma. These findings, and improved understanding of other relevant exposures, could steer the direction of primary (and secondary) disease prevention research. Moreover, careful identification of asthma characteristics has effectively established predictors of exacerbations, highlighting individuals for which additional therapies are warranted and for whom such treatments are most likely to be effective.

LEAP: A randomized-controlled trial of a lay-educator inpatient asthma education program

OBJECTIVE

To evaluate the impact of LEAP, a volunteer-based, inpatient asthma education program for families of inner-city children with asthma.

METHODS

711 children ages 2-17 years admitted with status asthmaticus were randomized to receive usual care or usual care plus a supplemental education intervention. Both groups completed a baseline interview. Trained volunteer lay educators conducted individualized bedside education with the intervention group. Primary outcome was attendance at a post-hospitalization follow-up visit 7-10 days after discharge. Secondary outcomes included parent-reported asthma management behaviors, symptoms, and self-efficacy scores from a one month follow-up interview.

RESULTS

Post-hospitalization asthma clinic attendance was poor (38%), with no difference between groups. Families randomized to the intervention group were more likely to report use of a controller (OR 2.4, 95% CI 1.3-4.2, p<0.01) and a valved-holding chamber (OR 2.9, 95% CI 1.1-7.4, p=0.03), and were more likely to have an asthma action plan at follow up (OR 2.0, 95% CI 1.3-3.0, p<0.01). Asthma self-efficacy scores were significantly improved among those who received the intervention (p=0.04).

CONCLUSIONS

Inpatient asthma education by trained lay volunteers was associated with improved asthma management behaviors.

PRACTICE IMPLICATIONS

This novel volunteer-based program could have widespread implications as a sustainable model for asthma education.