Inner-city asthma: the role of the community

A randomized pilot trial of a school-based psychoeducational intervention for children with asthma

BACKGROUND

Asthma is a common childhood illness with high morbidity and mortality among minority and socio-economically disadvantaged children. Disparities are not fully accounted for by differences in asthma prevalence, highlighting a need for interventions targeting factors associated with poorer asthma control. One such factor is psychological stress.

OBJECTIVE

Here, we examine the feasibility and acceptability of "I Can Cope (ICC)," a school-based stress management and coping intervention for children with asthma.

METHODS

A parallel randomized pilot trial was conducted. One hundred and four low-income children (mean age 10 years; 54% male; 70% African American) with persistent asthma were recruited from 12 urban schools and randomized to the following: (a) ICC or one of two control conditions: (b) "Open Airways for Schools (OAS)"-an asthma education intervention or (c) no treatment.

RESULTS

Seventy one percentage of eligible children participated in the study, with a dropout rate of 12%. ICC was rated as highly acceptable by participating children and parents. Preliminary efficacy data suggest that when compared with no treatment, ICC resulted in decreased symptoms of depression, perceived stress and child-reported symptoms of asthma, and improvements in sleep quality and child-reported asthma control. There were no intervention-related changes in objective measures of asthma morbidity. The magnitude of intervention effects on psychological function did not differ between the ICC and OAS groups.

CONCLUSIONS

Results support the feasibility and acceptability of utilizing school-based interventions to access hard to reach children with asthma. Preliminary findings offer support for future, large-scale efficacy studies of school-based interventions designed to target multiple factors that contribute to asthma disparities.

Epistemic tensions between people living with asthma and healthcare professionals in clinical encounters

RATIONALE

Asthma is a common respiratory condition with high prevalence rates globally. While there are effective treatments, asthma remains an important health concern as people continue to die from severe attacks. Improving the experiences of, and health outcomes for, people with asthma depends heavily on their interactions with healthcare professionals. Understanding negative clinical encounters will benefit people with asthma and healthcare providers.

OBJECTIVE

To examine epistemic tensions in negative clinical encounters from a patient perspective, with an aim to better understand how patients respond to these tensions. Much of the scholarship on patient interactions with healthcare providers examines interpersonal or structural factors. Thus, focusing our analysis on tensions between lay and expert knowledge in negative clinical encounters provides a novel contribution to this body of scholarship.

METHOD

As part of a larger qualitative study (n = 70) examining the lived experiences of people who have asthma or a child with asthma, semi-structured interviews with 17 participants who described having negative clinical encounters were analyzed for themes.

RESULTS

Participants responded to epistemic tensions in two main ways: (1) by incorporating expert knowledge; and (2) by resisting/challenging expert knowledge. In both cases, participants also described feeling frustrated and uncertain about their or their child's clinical care. We analyze these responses by drawing on Lindström and Karlsson's (2016) conceptualization of epistemic tensions as arising from 3 characteristics of epistemic asymmetry: access, rights, and responsibility.

CONCLUSION

Based on this study, (1) a patient's confidence in claiming epistemic access and asserting epistemic rights when epistemic tensions arise are related to the context and their own history of living with asthma; and (2), epistemic tensions can make visible the power relations in the patient-clinician relationship, which can lead to the exertion of biomedical authority, or the taking up of patient's lay knowledge.

Culture-specific programs for children and adults from minority groups who have asthma

BACKGROUND

People with asthma who come from minority groups often have poorer asthma outcomes, including more acute asthma-related doctor visits for flare-ups. Various programmes used to educate and empower people with asthma have previously been shown to improve certain asthma outcomes (e.g. adherence outcomes, asthma knowledge scores in children and parents, and cost-effectiveness). Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual, and not just the symptoms of the disease. Therefore, questions about whether tailoring asthma education programmes that are culturally specific for people from minority groups are effective at improving asthma-related outcomes, that are feasible and cost-effective need to be answered.

OBJECTIVES

To determine whether culture-specific asthma education programmes, in comparison to generic asthma education programmes or usual care, improve asthma-related outcomes in children and adults with asthma who belong to minority groups.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, Embase, review articles and reference lists of relevant articles. The latest search fully incorporated into the review was performed in June 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups with asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected, extracted and assessed the data for inclusion. We contacted study authors for further information if required.

MAIN RESULTS

In this review update, an additional three studies and 220 participants were added. A total of seven RCTs (two in adults, four in children, one in both children and adults) with 837 participants (aged from one to 63 years) with asthma from ethnic minority groups were eligible for inclusion in this review. The methodological quality of studies ranged from very low to low. For our primary outcome (asthma exacerbations during follow-up), the quality of evidence was low for all outcomes. In adults, use of a culture-specific programme, compared to generic programmes or usual care did not significantly reduce the number of participants from two studies with 294 participants for: exacerbations with one or more exacerbations during follow-up (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.50 to 1.26), hospitalisations over 12 months (OR 0.83, 95% CI 0.31 to 2.22) and exacerbations requiring oral corticosteroids (OR 0.97, 95% CI 0.55 to 1.73). However, use of a culture-specific programme, improved asthma quality of life scores in 280 adults from two studies (mean difference (MD) 0.26, 95% CI 0.17 to 0.36) (although the MD was less then the minimal important difference for the score). In children, use of a culture-specific programme was superior to generic programmes or usual care in reducing severe asthma exacerbations requiring hospitalisation in two studies with 305 children (rate ratio 0.48, 95% CI 0.24 to 0.95), asthma control in one study with 62 children and QoL in three studies with 213 children, but not for the number of exacerbations during follow-up (OR 1.55, 95% CI 0.66 to 3.66) or the number of exacerbations (MD 0.18, 95% CI -0.25 to 0.62) among 100 children from two studies.

AUTHORS' CONCLUSIONS

The available evidence showed that culture-specific education programmes for adults and children from minority groups are likely effective in improving asthma-related outcomes. This review was limited by few studies and evidence of very low to low quality. Not all asthma-related outcomes improved with culture-specific programs for both adults and children. Nevertheless, while modified culture-specific education programs are usually more time intensive, the findings of this review suggest using culture-specific asthma education programmes for children and adults from minority groups. However, more robust RCTs are needed to further strengthen the quality of evidence and determine the cost-effectiveness of culture-specific programs.

Use of Medicaid and housing data may help target areas of high asthma prevalence

OBJECTIVE

To determine if there was a significant difference between mold contamination and asthma prevalence in Detroit and non-Detroit Michigan homes, between newer and older homes, and if there is a correlation between mold contamination and measures of Medicaid use for asthma in the 25 Detroit zip codes.

METHODS

Settled dust was collected from homes (n = 113) of Detroit asthmatic children and from a representative group of Michigan homes (n = 43). The mold contamination for each home was measured using the Environmental Relative Moldiness Index (ERMI) scale and the mean ERMI values in Detroit and non-Detroit homes were statistically compared. Michigan Medicaid data (13 measures related to asthma) in each of the 25 zip codes in Detroit were tested for correlation to ERMI values for homes in those zip codes.

RESULTS

The mean ERMI value (14.5 ± 8.0) for Detroit asthmatic childrens' homes was significantly (Student's t-test, p < 0.001) greater than the mean ERMI value (2.1 ± 6.2) for the non-Detroit homes. Detroit homes > 60 years old had significantly (p = 0.01) greater mean ERMI values than Detroit homes ≤ 60 years old (15.87 vs. 11.25). The percentage of children that underwent spirometry testing for their persistent asthma (based on Medicaid data) was significantly, positively correlated with the mean ERMI values of the homes in the 25 zip codes.

CONCLUSIONS

Applying Medicaid-use data for spirometry testing and locating a city's older housing stock might help find foci of homes with high ERMI values.

A Citizen-Science Study Documents Environmental Exposures and Asthma Prevalence in Two Communities

A citizen-science study was conducted in two low-income, flood-prone communities in Atlanta, Georgia, in order to document environmental exposures and the prevalence of occupant asthma. Teams consisting of a public-health graduate student and a resident from one of the two communities administered a questionnaire, inspected residences for mold growth, and collected a dust sample for quantifying mold contamination. The dust samples were analyzed for the 36 molds that make up the Environmental Relative Moldiness Index (ERMI). Most residents (76%) were renters. The median duration of residence was 2.5 years. Although only 12% of occupants reported a history of flooding, 46% reported at least one water leak. Homes with visible mold (35%) had significantly (P < 0.05) higher mean ERMI values compared to homes without (14.0 versus 9.6). The prevalence of self-reported, current asthma among participants was 14%. In logistic regression models controlling for indoor smoking, among participants residing at their current residence for two years or less, a positive association was observed between asthma and the homes' ERMI values (adjusted odds ratio per unit increase in ERMI = 1.12, 95% confidence intervals (CI): 1.01-1.25; two-tailed P = 0.04). Documentation of the exposures and asthma prevalence has been presented to the communities and public officials. Community-based organizations have taken responsibility for planning and implementing activities in response to the study findings.

Family hardships and serum cotinine in children with asthma

BACKGROUND AND OBJECTIVE

A better understanding of how poverty-related hardships affect child health could highlight remediable intervention targets. Tobacco smoke exposure may be 1 such consequence of family hardship. Our objective was to explore the relationship between family hardships and tobacco exposure, as measured by serum cotinine, a tobacco metabolite, among children hospitalized for asthma.

METHODS

We prospectively enrolled a cohort of 774 children, aged 1 to 16 years, admitted for asthma or bronchodilator-responsive wheezing. The primary outcome was detectable serum cotinine. We assessed family hardships, including 11 financial and social variables, through a survey of the child's caregiver. We used logistic regression to evaluate associations between family hardship and detectable cotinine.

RESULTS

We had complete study data for 675 children; 57% were African American, and 74% were enrolled in Medicaid. In total, 56% of children had detectable cotinine. More than 80% of families reported ≥ 1 hardship, and 41% reported ≥ 4 hardships. Greater numbers of hardships were associated with greater odds of having detectable cotinine. Compared with children in families with no hardships, those in families with ≥ 4 hardships had 3.7-fold (95% confidence interval, 2.0-7.0) greater odds of having detectable serum cotinine in adjusted analyses. Lower parental income and educational attainment were also independently associated with detectable serum cotinine.

CONCLUSIONS

Family hardships are prevalent and associated with detectable serum cotinine level among children with asthma. Family hardships and tobacco smoke exposure may be possible targets for interventions to reduce health disparities.

Inequalities in neighborhood child asthma admission rates and underlying community characteristics in one US county

OBJECTIVES

To characterize variation and inequalities in neighborhood child asthma admission rates and to identify associated community factors within one US county.

STUDY DESIGN

This population-based prospective, observational cohort study consisted of 862 sequential child asthma admissions among 167 653 eligible children ages 1-16 years in Hamilton County, Ohio. Admissions occurred at a tertiary-care pediatric hospital and accounted for nearly 95% of in-county asthma admissions. Neighborhood admission rates were assessed by geocoding addresses to city- and county-defined neighborhoods. The 2010 US Census provided denominator data. Neighborhood admission distribution inequality was assessed by the use of Gini and Robin Hood indices. Associations between neighborhood rates and socioeconomic and environmental factors were assessed using ANOVA and linear regression.

RESULTS

The county admission rate was 5.1 per 1000 children. Neighborhood rates varied significantly by quintile: 17.6, 7.7, 4.9, 2.2, and 0.2 admissions per 1000 children (P < .0001). Fifteen neighborhoods containing 8% of the population had zero admissions. The Gini index of 0.52 and Robin Hood index of 0.38 indicated significant inequality. Neighborhood-level educational attainment, car access, and population density best explained variation in neighborhood admission rates (R(2) = 0.55).

CONCLUSION

In a single year, asthma admission rates varied 88-fold across neighborhood quintiles in one county; a reduction of the county-wide admission rate to that of the bottom quintile would decrease annual admissions from 862 to 34. A rate of zero was present in 15 neighborhoods, which is evidence of what may be attainable.

A multifaceted community-based asthma intervention in Chicago: effects of trigger reduction and self-management education on asthma morbidity

OBJECTIVES

Home-based, multifaceted interventions have been effective in reducing asthma morbidity in children. However, identification of independent components that contribute to outcomes and delineating effectiveness by level of asthma symptoms would help to refine the intervention and target appropriate populations.

METHODS

A community health educator led asthma intervention implemented in a low-income African-American neighborhood included asthma management education, individually tailored low-cost asthma home trigger remediation, and referrals to social and medical agencies, when appropriate. Changes in asthma morbidity measures were assessed in relation to implementation of individual intervention components using multivariable logistic regression.

RESULTS

Among the 218 children who completed the year-long program, there were significant reductions in measures of asthma morbidity, including symptoms, urgent care visits, emergency department (ED) visits, hospitalizations, missed school days, and missed work days for caretakers. We also found significant decreases in the prevalence of many home asthma triggers and improvements in asthma management practices. Improvement in caretaker's ability to manage the child's asthma was associated with reduction in ED visits for asthma and uncontrolled asthma. Specific home interventions, such as repair of water leaks and reduced exposure to plants, dust, clutter and stuffed toys, may be related to reduction in asthma morbidity.

CONCLUSIONS

This program was effective in reducing asthma morbidity in low-income African-American children and identified specific interventions as possible areas to target in future projects. Furthermore, the intervention was useful in children with persistent asthma symptoms as well as those with less frequent asthma exacerbations.

Psychosocial factors and behavioral medicine interventions in asthma

OBJECTIVE

This review examines the evidence for psychosocial influences in asthma and behavioral medicine approaches to its treatment.

METHOD

We conducted a systematic review of the literature on psychosocial influences and the evidence for behavioral interventions in asthma with a focus on research in the past 10 years and clinical trials. Additional attention was directed at promising new developments in the field.

RESULTS

Psychosocial factors can influence the pathogenesis and pathophysiology of asthma, either directly through autonomic, endocrine, immunological, and central nervous system mechanisms or indirectly through lifestyle factors, health behaviors, illness cognitions, and disease management, including medication adherence and trigger avoidance. The recent decade has witnessed surging interest in behavioral interventions that target the various pathways of influence. Among these, self-management training, breathing training, and exercise or physical activation programs have proved particularly useful, whereas other essential or promising interventions, such as smoking cessation, dietary programs, perception and biofeedback training, and suggestive or expressive psychotherapy, require further, more rigorous evaluation. Given the high comorbidity with anxiety and mood disorders, further evaluation of illness-specific cognitive behavior therapy is of particular importance. Progress has also been made in devising community-based and culturally tailored intervention programs.

CONCLUSION

In concert with an essential medication treatment, behavioral medicine treatment of asthma is moving closer toward an integrated biopsychosocial approach to disease management.

Stress and quality of life in caregivers of inner-city minority children with poorly controlled asthma

INTRODUCTION

Caregiver quality of life (QOL) is known to influence asthma management behaviors. Risk factors for low caregiver QOL in families of inner-city children with asthma remain unclear. This study evaluated the interrelationships of asthma control, stress, and caregiver QOL.

METHOD

Data were analyzed from a home-based behavioral intervention for children with persistent asthma after treatment for asthma in the emergency department. Caregivers reported on baseline demographics, asthma control, asthma management stress, life stress, and QOL. Hierarchical regression analysis examined the contributions of sociodemographic factors, asthma control, asthma management stress, and life stress in explaining caregiver QOL.

RESULTS

Children (N = 300) were primarily African American (96%) and young (mean age, 5.5 years). Caregivers were predominantly the biological mother (92%), single (70%), and unemployed (54%). Poor QOL was associated with higher caregiver education and number of children in the home, low asthma control, and increased asthma management stress and life stress. The model accounted for 28% of variance in caregiver QOL.

DISCUSSION

Findings underscore the need for multifaceted interventions to provide tools to caregivers of children with asthma to help them cope with asthma management demands and contemporary life stressors.

Identifying and treating a substandard housing cluster using a medical-legal partnership

BACKGROUND AND OBJECTIVE

There is a documented connection between the home environment and health. Medical-legal partnerships (MLPs) can address social and environmental determinants of health. Our objective was to describe a cluster of substandard housing identified and treated by an MLP based in a pediatric primary care setting.

METHODS

Potential cases of poor-quality housing were identified during outpatient primary care. A case was defined as any rented housing unit with a reported unaddressed housing risk within a defined building portfolio (owned by a single developer) in which ≥ 1 child lived. An on-site MLP offered affected families legal services including ordinance enforcement and connection to resources. They also initiated portfolio-wide advocacy. Legal advocates reported case outcomes. Medical history and household demographics were collected from the medical record and compared with clinic-wide data by using Fisher's exact test or χ(2) statistics.

RESULTS

After identification of a single case, an additional 15 cases were identified. Pest infestation was the most common initial risk identified. Of 14 units with outcome data, repairs were completed in 10 (71%). Of the 19 building complexes with the same owner, 11 received significant systemic repairs. Of the 45 children living within the 16 identified case units, 36% had asthma, 33% had developmental delay or behavioral disorder, and 9% had an elevated lead level. Affected children were more likely to have one of these diagnoses than the general clinic population (all P < .01).

CONCLUSIONS

An MLP identified and improved home environmental conditions for children living in a cluster of substandard housing.

Environmental improvements brought by the legal interventions in the homes of poorly controlled inner-city adult asthmatic patients: a proof-of-concept study

OBJECTIVES

Domestic contamination with mold, cockroaches, rodents, and dust worsens asthma severity. This violates warranty of habitability laws in most of the states, but patients often find it beyond their means to remedy their housing situation. We aimed to study the effect of a medical-legal collaborative intervention to force landlords into providing better living conditions for patients with poorly controlled asthma.

METHODS

We retrospectively studied charts of adult patients aged 18 years or older with poorly controlled asthma (moderate or severe persistent) despite maximum medical therapy. Additionally, patients had self-reported domestic allergen exposures such as mold, cockroaches, mice or rats, and dust. The patients received legal assistance to improve their domestic environments, including fixing leaks, exterminating pests, or providing a different apartment. Post-intervention change in peak expiratory flow rate (PEFR), asthma severity class, medications, emergency department (ED) visits, hospitalizations, and requirement for systemic steroids for symptom control was assessed.

RESULTS

Data were available for 12 patients (9-12 months pre-intervention and 6-12 months post-intervention). Analysis of paired data revealed that mean PEFR rose by 38.6 LPM (95% CI: 9.9-67.3; p = .014). The number of ED visits and hospital admissions declined from 22 ED visits and 11 admissions to 2 ED visits and 1 admission (91% reduction), respectively. Of the 11 patients requiring systemic steroids, only three required these post-intervention. All patients had reductions in the dose and/or number of medications. During post-intervention, 11 (91.7%) patients dropped ≥2 classes in asthma severity.

CONCLUSIONS

Medical-legal collaboration is highly effective in improving the control of inner-city asthmatics by effecting improvements in the domestic environment.

'Relax and take a deep breath': print media coverage of asthma and air pollution in the United States

The media are an important social actor in the construction of the public's understanding of the complex relationships between the environment and their health. This paper explores the print media's coverage of the relationship between asthma and air pollution, focusing on the portrayal of causal certainty between exposure to various forms of air pollution and the etiology and exacerbation of the disease. By examining twenty years of newspaper articles from the New York Timeş Los Angeles Times, and the Washington Post, this paper presents findings on trends across time, within papers, and across key themes. Although the print media's coverage of asthma and its environmental correlates has increased over time, this paper finds relatively little coherence in whether asthma is portrayed as directly caused by air pollution or triggered by exposures. In terms of coverage, outdoor sources of air pollution are covered more frequently - but with less certainty in the discussion of specific relationships. This lack of coherence and specificity in the portrayal of asthma as an environmental disease may weaken regulators' ability to act in passing air pollution reforms by lowering the public's interest and concern.

Community-based care coordination: practical applications for childhood asthma

Care coordination programs have been used to address chronic illnesses, including childhood asthma, but primarily via practice-based models. An alternative approach employs community-based care coordinators who bridge gaps between families, health care providers, and support services. Merck Childhood Asthma Network, Inc. (MCAN) sites developed community-based care coordination approaches for childhood asthma. Using a community-based care coordination logic model, programs at each site are described along with program operational statistics. Four sites used three to four community health workers (CHWs) to provide care coordination, whereas one site used five school-based asthma nurses. This school-based site had the highest caseload (82.5 per year), but program duration was 3 months with 4 calls or visits. Other sites averaged fewer cases (35 to 61 per CHW per year), but families received more (7 to 17) calls or visits over a year. Retention was 43% to 93% at 6 months and 24% to 75% at 12 months. Pre-post cross-site data document changes in asthma management behaviors and outcomes. After program participation, 93% to 100% of caregivers had confidence in controlling their child's asthma, 85% to 92% had taken steps to reduce triggers, 69% to 100% had obtained an asthma action plan, and 46% to 100% of those with moderate to severe asthma reported appropriate use of controller medication. Emergency department visits for asthma decreased by 36% to 63%, and asthma-related hospitalizations declined by 26% to 78%. More than three fourths had fewer school absences. In conclusion, MCAN community-based care coordination programs improved management behaviors and decreased morbidity across all sites.

Preliminary evidence for the feasibility of a stress management intervention for 7- to 12-year-olds with asthma

OBJECTIVE

Evidence supports a bidirectional relationship between stress and asthma exacerbations in children, suggesting that interventions to reduce stress may improve both psychosocial quality of life and disease course. Here, we examine the feasibility of a stress management intervention for 7- to 12-year-olds with asthma.

METHODS

Two trials were conducted. Cohort 1 (n = 11) was recruited from the community and attended intervention sessions at an urban university. Cohort 2 (n = 7) was school based and recruited from an African American charter school. Six individual intervention sessions focused on psychoeducation about asthma, stress, and emotions; problem-solving and coping skills training; and relaxation training paired with physiological feedback. Pre- and post-intervention stress, mood, and lung function data were collected. Satisfaction surveys were administered after intervention completion.

RESULTS

The intervention was rated as highly acceptable by participating families. Feasibility was much stronger for the school-based than the university-based recruitment mechanism. Initial efficacy data suggest that both cohorts showed pre- to post-intervention improvements in lung function, perceived stress, and depressed mood.

CONCLUSION

Findings provide evidence for the feasibility of offering asthma-related stress management training in a school setting. Initial findings offer support for future, large-scale efficacy studies.

Association of depression, psycho-social stress and acculturation with respiratory disease among Puerto Rican adults in Massachusetts

To assess associations between acculturation, depression, and self-reported stress score with reported diagnosis of respiratory disease (RD) in Puerto Rican adults, participants (N = 1,168) were identified from areas of high Hispanic density in the Boston, MA metropolitan area. Eligible participants were interviewed in the home by bilingual interviewers in either Spanish or English. Scales included topics ranging from general background to depressive symptomatology. Respiratory disease was self-reported and checked against prescribed medication. More than one-third (37.8%) of subjects reported doctor-diagnosed RD. A final binary logistical regression model (N = 850), which was adjusted for potential confounders (sex, age, education, poverty) showed that RD was significantly associated with psychological acculturation (OR = 1.97, P = 0.005), depressive symptomatology (OR = 1.52, P = 0.03) high perceived stress score (OR = 1.97, P = 0.009), and current smoking (OR = 1.61, P = 0.03). Significant inverse associations included a high level of language acculturation (OR = 0.65, P = 0.03), light (OR = 0.67, P = 0.01) and moderate to heavy physical activity versus sedentary physical activity (OR = 0.40, P = 0.03). We found self reported physician diagnosed RD was associated with high perceived stress and depression, as well as higher levels of psychological acculturation. Longitudinal research is needed to determine if there is a causal pathway for these associations.

Effect of a community-wide asthma intervention on appropriate use of inhaled corticosteroids

Individuals with asthma living in the inner city experience increased asthma morbidity and mortality compared to the US average. The Controlling Asthma in America's Cities Project's Chicago site used a multifaceted approach to improve asthma care. The diverse scope of this project's interventions necessitated the use of novel methods to assess the effect of these interventions on the entire study area. Asthma-related medication-dispensing data were obtained from a large pharmacy chain for prescriptions filled in calendar years 2004-2006 for all individuals aged 5-17 years living in Chicago who filled at least four asthma-related medications within a 12-month period. Inhaled corticosteroid (ICS) use was considered inadequate if an individual had four or more dispensings of a short-acting beta-agonist without at least four dispensings of an ICS agent. Logistic regression was used to compare adequate ICS use in individuals within the intervention area with ICS use in the remainder of the city, after controlling for gender, insurance status, race, and poverty. A significant difference in adequate ICS use was found in years 2 (2005) and 3 (2006) of the project for individuals aged 5-9 in the intervention area (odds ratios for adequate ICS use-year 2, 1.26; CI, 1.04-1.53, p = 0.04; year 3, 1.30; CI, 1.08-1.55, p = 0.008) compared to individuals aged 5-9 in the remainder of the city. There was no similar significant difference in the 10-17 age group. These findings suggest an effect of a large multifaceted asthma intervention in improving medication use in the targeted age group. This methodology might also prove useful in the future for assessing the effect of similar interventions.

Toward the assessment of scientific and public health impacts of the National Institute of Environmental Health Sciences Extramural Asthma Research Program using available data

BACKGROUND

In the past 15 years, asthma prevalence has increased and is disproportionately distributed among children, minorities, and low-income persons. The National Institute of Environmental Health Sciences (NIEHS) Division of Extramural Research and Training developed a framework to measure the scientific and health impacts of its extramural asthma research to improve the scientific basis for reducing the health effects of asthma.

OBJECTIVES

Here we apply the framework to characterize the NIEHS asthma portfolio's impact in terms of publications, clinical applications of findings, community interventions, and technology developments.

METHODS

A logic model was tailored to inputs, outputs, and outcomes of the NIEHS asthma portfolio. Data from existing National Institutes of Health (NIH) databases are used, along with publicly available bibliometric data and structured elicitation of expert judgment.

RESULTS

NIEHS is the third largest source of asthma-related research grant funding within the NIH between 1975 and 2005, after the National Heart, Lung, and Blood Institute and the National Institute of Allergy and Infectious Diseases. Much of NIEHS-funded asthma research focuses on basic research, but results are often published in journals focused on clinical investigation, increasing the likelihood that the work is moved into practice along the "bench to bedside" continuum. NIEHS support has led to key breakthroughs in scientific research concerning susceptibility to asthma, environmental conditions that heighten asthma symptoms, and cellular mechanisms that may be involved in treating asthma.

CONCLUSIONS

If gaps and limitations in publicly available data receive adequate attention, further linkages can be demonstrated between research activities and public health improvements. This logic model approach to research impact assessment demonstrates that it is possible to conceptualize program components, mine existing databases, and begin to show longer-term impacts of program results. The next challenges will be to modify current data structures, improve the linkages among relevant databases, incorporate as much electronically available data as possible, and determine how to improve the quality and health impact of the science that we support.

Culture-specific programs for children and adults from minority groups who have asthma

BACKGROUND

People with asthma who come from minority groups have poorer asthma outcomes and more asthma related visits to Emergency Departments (ED). Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual and not just the symptoms of the disease. Therefore, questions about whether culturally specific asthma education programmes for people from minority groups are effective at improving asthma outcomes, are feasible and are cost-effective need to be answered.

OBJECTIVES

To determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma related outcomes in children and adults with asthma who belong to minority groups.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The latest search was performed in May 2008.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups who suffer from asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected, extracted and assessed the data for inclusion. We contacted authors for further information if required.

MAIN RESULTS

Four studies were eligible for inclusion in the review. A total of 617 patients, aged from 5 to 59 years were included in the meta-analysis of data. Use of a culture-specific programme was superior to generic programmes or usual care, in improving asthma quality of life scores in adults, pooled WMD 0.25 (95% CI 0.09 to 0.41), asthma knowledge scores in children, WMD 3.30 (95% CI 1.07 to 5.53), and in a single study, reducing asthma exacerbation in children (risk ratio for hospitalisations 0.32, 95%CI 0.15, 0.70).

AUTHORS' CONCLUSIONS

Current limited data show that culture-specific programmes for adults and children from minority groups with asthma, are more effective than generic programmes in improving most (quality of life, asthma knowledge, asthma exacerbations, asthma control) but not all asthma outcomes. This evidence is limited by the small number of included studies and the lack of reported outcomes. Further trials are required to answer this question conclusively.

Asthma morbidity in adult Chicago public housing residents

BACKGROUND

Residents of public housing can experience socioeconomic disadvantages, inadequate access to health care, and particularly substandard indoor air quality due to inadequate building maintenance.

OBJECTIVE

This study investigates demographic, medical management, severity, and household factors associated with asthma-related emergency department visits and hospitalizations.

METHODS

A total of 103 adult participants with asthma from four Chicago housing developments completed surveys and underwent household inspections.

RESULTS

Using stepwise multivariate logistic regression, we identified independent predictors of asthma-related emergency department visits: asthma controller medication use, not keeping an asthma-related doctor's appointment, and frequent nocturnal wheeze episodes. Using stepwise multivariate logistic regression, we identified independent predictors of asthma-related hospitalizations: peeling paint, plaster, or wallpaper, environmental tobacco smoke, written action plan for an asthma-related doctor or emergency department visit, and frequent nocturnal wheeze episodes.

CONCLUSIONS

In multivariate models, factors related to clinical severity and asthma management were related to both emergency department visits and hospitalizations while household conditions were related only to hospitalizations. Interventions to address both asthma management and household environmental triggers may be needed to reduce asthma morbidity in low-income populations.

Acute exacerbations of asthma: epidemiology, biology and the exacerbation-prone phenotype

Asthma is a highly prevalent chronic respiratory disease affecting 300 million people world-wide. A significant fraction of the cost and morbidity of asthma derives from acute care for asthma exacerbations. In the United States alone, there are approximately 15 million outpatient visits, 2 million emergency room visits, and 500,000 hospitalizations each year for management of acute asthma. Common respiratory viruses, especially rhinoviruses, cause the majority of exacerbations in children and adults. Infection of airway epithelial cells with rhinovirus causes the release of pro-inflammatory cytokines and chemokines, as well as recruitment of inflammatory cells, particularly neutrophils, lymphocytes, and eosinophils. The host response to viral infection is likely to influence susceptibility to asthma exacerbation. Having had at least one exacerbation is an important risk factor for recurrent exacerbations suggesting an 'exacerbation-prone' subset of asthmatics. Factors underlying the 'exacerbation-prone' phenotype are incompletely understood but include extrinsic factors: cigarette smoking, medication non-compliance, psychosocial factors, and co-morbidities such as gastroesophageal reflux disease, rhinosinusitis, obesity, and intolerance to non-steroidal anti-inflammatory medications; as well as intrinsic factors such as deficient epithelial cell production of the anti-viral type I interferons (IFN-alpha and IFN-beta). A better understanding of the biologic mechanisms of host susceptibility to recurrent exacerbations will be important for developing more effective preventions and treatments aimed at reducing the significant cost and morbidity associated with this important global health problem.

Control of asthma

Control is the aim of asthma management and clinical trials show that control can be achieved in the majority of patients. However, population surveys show that poorly controlled asthma still imposes a considerable burden. This fact has led to a re-evaluation of the international asthma guidelines and the updated 2006 and 2007 GINA and NAEPP guidelines suggest that the level of control should be used as the key feature for the classification and management of asthma. Furthermore, in the latest guidelines, a clearer definition of control is given and new tools for the assessment and monitoring of control are instituted. In order to achieve asthma control, not only relevant pharmacological treatment but, the establishment of a good patient-doctor relationship, proper education of the asthmatic patient, reduction of exposure to triggers and treatment of co-morbidities are pivotal issues and must be ensured.

Culture-specific programs for children and adults from minority groups who have asthma

BACKGROUND

People with asthma who come from minority groups have poorer asthma outcomes and more asthma related visits to Emergency Departments (ED). Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual and not just the symptoms of the disease. Therefore, questions about whether culturally specific asthma education programmes for people from minority groups are effective at improving asthma outcomes, are feasible and are cost-effective need to be answered.

OBJECTIVES

To determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma related outcomes in children and adults with asthma who belong to minority groups.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The latest search was performed in May 2008.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups who suffer from asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected, extracted and assessed the data for inclusion. We contacted authors for further information if required.

MAIN RESULTS

Four studies were eligible for inclusion in the review. A total of 617 patients, aged from 5 to 59 years were included in the meta-analysis of data. Use of a culture-specific programme was superior to generic programmes or usual care, in improving asthma quality of life scores in adults, pooled WMD 0.25 (95% CI 0.09 to 0.41), asthma knowledge scores in children, WMD 3.30 (95% CI 1.07 to 5.53), and in a single study, reducing asthma exacerbation in children (risk ratio for hospitalisations 0.32, 95%CI 0.15, 0.70).

AUTHORS' CONCLUSIONS

Current limited data show that culture-specific programmes for adults and children from minority groups with asthma, are more effective than generic programmes in improving most (quality of life, asthma knowledge, asthma exacerbations, asthma control) but not all asthma outcomes. This evidence is limited by the small number of included studies and the lack of reported outcomes. Further trials are required to answer this question conclusively.

Efficacy of an outdoor air pollution education program in a community at risk for asthma morbidity

BACKGROUND

Asthma management guidelines recommend avoiding exposure to indoor and outdoor air pollutants. A limitation of such recommendations is that they do not provide information about how the public should obtain and act on air quality information. Although the Air Quality Index (AQI) provides simplified outdoor air quality forecasts, communities with high rates of asthma morbidity tend to have low rates of internet access due to factors such as low socioeconomic status. Assessments of knowledge about air quality among low-income minority communities are lacking, as are community-based programs to educate the public about using the AQI.

METHODS

An air quality education program and system for disseminating air quality information were developed to promote pollutant avoidance during the reconstruction of a major highway in a low-income minority community on Chicago's South Side. The program, which centered on workshops run by community asthma educators, was evaluated using a pre-test, post-test, and 1-year follow-up questionnaire.

RESULTS

A total of 120 community workshop participants completed at least a portion of the evaluation process. At baseline, knowledge about air quality was limited. Following the workshops, substantial increases were noted in rates of correct answers to questions about health effects of air pollution, the availability of air quality information, and the color code for an AQI category. Approximately 1 year after the workshops were held, few participants could recall elements of the training. Few participants have internet access, and alternative means of distributing air quality information were suggested by study participants.

CONCLUSIONS

Baseline knowledge of air quality information was limited in the community studied. Air quality education workshops conducted by community educators can increase knowledge about outdoor air quality and its impact on health over the short term. Refresher workshops or other efforts to sustain the knowledge increase may be useful. Given the known short-term and long-term effects of air quality on morbidity and mortality, air quality education efforts should be further developed, evaluated, and promoted for the general public, for people with underlying cardiopulmonary disease, and given the documented health disparities within the general population, for low-income and minority communities.