Key Points
- •
Racial and ethnic minorities and children with low socioeconomic status living in urban communities have a disproportionate burden of asthma morbidity, mortality and healthcare use.
- •
Successful interventions targeting inner city children with asthma must be multifactorial and take into account access to care, social, environmental and behavioral factors.
- •
Community linkages, epidemiologic evaluation, self-management, decision support and improved patient-provider communication are essential ingredients of asthma management programs.
- •
It is important to determine individual risks and tailor asthma interventions in the context of the physical and social environments.
- •
Translation of successful evidence-based interventions into practice presents a challenge that requires evaluation and feedback from those implementing these interventions at the community level.
Wide variations exist in the prevalence of childhood asthma worldwide, ranging from less than 1% to as high as 37%. The National Health Interview Survey in 2012 reported that 9.3% of children under age 18 in the USA have asthma and 14% have been diagnosed with asthma at some time in their lives. Small area analyses have demonstrated asthma period prevalence rate in poor urban communities in the USA to be twice the national prevalence rate. Children in poor families are more likely to have current asthma than children in families that are not poor (13% vs 8%). There is variation in prevalence among ethnic groups. Puerto Rican children living in the Northeast USA reported some of the highest prevalence rates. Disparities in morbidity in addition to prevalence are evident. Hospitalization rates and emergency department (ED) visits are highest in poor urban areas. Reviews of asthma disparities find that African American and Hispanic children who live in low socioeconomic urban environments experience higher morbidity and mortality than white children. In the UK, blacks and south Asians are at significantly increased risk of admission for asthma.
Racial and ethnic minorities that are socioeconomically disadvantaged and disproportionately affected by asthma live predominantly in densely populated urban areas. These so-called ‘inner cities’ are not uniform in many of their characteristics. The differences include housing stock, climate, environmental exposures, race and ethnicity. As a result of the documented disparities in asthma morbidity, the inner cities have been the focus of studies to determine the characteristics of these areas that contribute to high prevalence and morbidity and to develop interventions.
The relationship of race/ethnicity, environment and socioeconomic status (SES) to asthma morbidity is complex. The hospital readmission rate for asthma is twice as high in African Americans compared to whites. In an attempt to characterize the racial disparities, one study found that traditional SES measures coupled with financial and social hardship explained 50% of the readmission rate. Behavioral factors and patterns of care also determine asthma outcome. Jones et al demonstrated that minority children with wheeze were nearly twice as likely as white children to have used urgent care for asthma, after controlling for disease severity, access to care and environmental factors. Puerto Rican children had more clinic visits for asthma but spent fewer days in the hospital for asthma than African American children. Health beliefs may differ among various cultures. Ethnic minorities with low incomes might regard asthma as less serious than other pressing problems of life. Low parental expectations and competing family priorities are associated with poor asthma control. In a multivariate analysis that included these factors in the analytic model, the association between race/ethnicity and poor asthma control was not significant. In summary, a variety of interrelated factors contribute to morbidity and multifaceted tailored interventions are more likely to succeed.
Challenges to Asthma Management
Despite the existence of effective disease control strategies and medications, asthma remains a major public health problem. Morbidity, direct and indirect healthcare costs and mortality continue to impose a high burden. Individual asthma care is only one component of effective asthma control. Compared with social, environmental and behavioral factors, medical care has only a relatively small influence on health for populations. The role of these factors was evident in the initial studies of the National Inner City Asthma Study (NCICAS). Poor housing stock, crowded living conditions and poor access to appropriate health care despite the availability of insurance are barriers. Exposure and sensitization to allergens such as cockroach and mouse, as well as exposure to indoor pollutants such as environmental tobacco smoke and nitrogen dioxide are high. It is important to note that these risk factors vary from one child to the next.
Interventions aimed at primary prevention of asthma in inner city children are lacking. Longitudinal birth cohort studies are underway that may drive novel interventions. These studies will increase our understanding of the interaction of prenatal factors, viral infections, environmental tobacco smoke, microbiome, epigenetics and stress in the development of asthma. There are no effective public health strategies or treatment regimes that reduce the risk of developing asthma or influence its natural history.
Evidence indicates that establishment of a successful asthma management program entails a logical progression through specific developmental stages, starting with political/stakeholder endorsement and commitment, followed by epidemiologic evaluation, evaluation of disease burden, evaluation of access to care and best therapy, and finally optimization and maintenance therapy for individual patients. Applying a model embodying these concepts in an inner city setting for patients with chronically poorly controlled asthma resulted in sustained improvement in asthma control in adolescent patients. The interventions implemented included delivery system redesign to provide standardized and evidence-based care, productive interactions between informed patients and prepared clinicians, self-management support, community linkages, clinical information systems and decision support.
Factors Contributing to Morbidity in Inner Cities ( Table 33-1 )
Asthma Knowledge and Patterns of Care
Insufficient caregiver and child asthma knowledge contributes to asthma morbidity but inability to apply the knowledge and change behavior also plays a role. The NCICAS found that although caregivers of inner city children had reasonably good asthma knowledge, they had difficulty giving responses that could be helpful in asthma management when they were given hypothetical vignettes. The caregiver’s expectations regarding his or her ability to manage the child’s asthma are predictive of the child’s functional status, suggesting that attitudes play a role in determining the child’s asthma outcome. Negative beliefs about medications and low expectations about the benefit of the medications are predisposing factors associated with poor clinical outcome. Low parental involvement and delays in recognizing symptoms and initiating therapy are also associated with poor outcomes. Patients and caregivers tolerate poor symptom control and possess inadequate knowledge of correct drug usage. Language barriers between provider and patient or caregiver contribute to underreporting of symptoms and suboptimal communication. The interactions are complex and interventions must identify breakdowns in the pathways to optimize outcomes ( Figure 33-1 ).
| Access to Care | Environment | Host | Psychosocial | Adherence |
|---|---|---|---|---|
| Underdiagnosis | Allergens | Genetics | Maternal factors | Child/caregiver |
| Undertreatment | Irritants | Obesity | Child factors | Healthcare provider |
| Availability of specialty care | Asthma knowledge | Stress | ||
| Insurance | Violence Housing |
Children with lower SES have fewer doctor visits despite more ED visits and hospitalizations. Most children have a usual source of primary care but when symptomatic with asthma have difficulty finding care outside the ED. Use of the ED leads to more fragmented care. Children use reliever medication more frequently than antiinflammatory medications. In a managed care setting in a low SES group, African Americans fill fewer prescriptions than Caucasians.
Adherence
Overall estimates for adherence to medications are about 50% ( Box 33-1 ). In adolescents, asthma prevention and management behaviors were suboptimal with only 36% of those prescribed medication for persistent asthma reporting taking medications daily. Adherence to an asthma management program involves use of controller medication, appointment keeping and applying an emergency plan of action. Barriers to adherence may exist in any of these areas, leading to ineffective control of asthma. Concern about side-effects and negative caregiver beliefs regarding efficacy of medications are more likely in nonadherent compared to adherent children. Studies show that caregivers of children with asthma have cultural beliefs about asthma medications that provide the rationale for limiting or discontinuing the use of medications. Even when a controller medication was prescribed by a physician, more than one third of caregivers did not report it, and this discordance was related to caregivers’ beliefs about treatment. Smith et al reported that suboptimal asthma control and controller medication underuse were highly associated with potentially modifiable risk factors, especially low parental expectations for functioning and symptom control, discordant estimation of asthma control, lack of routines for administering medication, and concerns about asthma medications. Results of a multivariate analysis suggested that low parental expectations and competing priorities mediated the association of race/ethnicity and poor asthma control. Complementary and alternative medicine use in children with asthma is high. Usage is highest in black, poor, lesser educated parents and in children with persistent asthma.
Insufficient asthma knowledge
Inability to translate knowledge into practice
Negative beliefs about medications
Cultural beliefs about medications
Low parental expectations for symptom control
Competing priorities
Suboptimal communication between parent and healthcare provider
The level of responsibility for asthma management increases with age in inner city children. However, older children may still be ill-equipped to manage the illness independently. A complicating factor is that there is discordance between the caregiver and the child regarding responsibility for the management of the child’s asthma.
Access to Care
Lack of adequate health insurance is an important barrier to healthcare services for children in the USA. Diagnosis and treatment of asthma are related to healthcare coverage. However, some evidence suggests that asthma-related healthcare differences across groups might exist independently of financial barriers. Despite very high levels of healthcare coverage and access to primary care in an urban population, the overall quality of asthma care and management falls short of that recommended by national guidelines. In the NCICAS, 91% of children had health insurance but only 28% received antiinflammatory medications. This suggests that the delivery or quality of care may contribute to poor outcome. Access to care from asthma specialists is reduced for those who are poor and belong to an ethnic minority. Physicians underprescribe controller medication for inner city children despite guidelines recommending the use of antiinflammatory medications for persistent asthma. Furhman et al reported that children with asthma hospitalized for an exacerbation had been consistently poorly controlled during the previous year. They were undertreated and insufficiently educated about asthma. However physician adherence to guidelines will not translate into appropriate treatment without attention being paid to caregiver-physician communication.
Psychosocial Factors
Behavioral and psychosocial factors can affect asthma morbidity. There are variations in asthma morbidity in neighborhoods with low SES. This indicates that asthma morbidity cannot be explained solely by economic factors and that community factors may be important. Exposure to violence was independently associated with asthma morbidity after simultaneous adjustment for income, employment status, caregiver education, housing problems and other adverse life events, which suggests that exposure to violence is not merely a marker for these other factors. Increased exposure to violence predicts increased symptomatology in a graded fashion. Children spend more time indoors because of fear of violence, which could potentially increase exposure to indoor allergens and irritants. Inner city school children with asthma whose primary caregivers perceived the neighborhood to be unsafe had an increased likelihood of poorly controlled asthma, increased use of rescue medication use and more limitation in activity and nighttime symptoms compared to participants living in safe neighborhoods.
Psychosocial factors, particularly the mental health of children and caregivers, are significant factors in predicting asthma morbidity. In the NCICAS, caregiver mental health as assessed by the Brief Symptom Inventory revealed that children of caregivers who had psychological symptoms were almost twice as likely to be hospitalized for asthma. In adolescents with asthma, number of asthma symptoms, asthma-related school absenteeism, physician visits for asthma and hospitalization for asthma were significantly associated with the number of stressful events, independent of environmental exposures and sociodemographic factors. Interventions that do not address psychosocial issues may have limited impact.
Indoor Environmental Exposures
Attention to the indoor environment is of particular importance because children living in urban areas spend approximately 70% of their time indoors, where they are exposed to irritants, allergens and endotoxin. There are many sources of indoor exposure penetrating from outdoor air and generating from indoor sources.
Exposure to environmental tobacco smoke (ETS) in children with asthma living in inner cities is high. Studies in inner cities report that more than half of children with asthma have one or more smokers in the household and over one third of primary caregivers of children with asthma are smokers. Measurement of cotinine levels in children reveal even higher levels of personal exposure ranging from 38% to 69%. African American children are more likely to be exposed than Latino children.
Particulate matter (PM) is a major source of indoor air pollution in inner city homes. Indoor concentrations of PM are related to combustion products as well as to variation in ventilation and air filtration. Penetration of particles from outdoor sources contributes about 25% of the indoor concentration. The major indoor source is smoking. In the Inner-City Air Pollution Study (ICAP) the mean indoor value of fine particulate matter (PM 2.5 ) in smoking homes was 46.5 µg/m 3 compared with 17.8 µg/m 3 in nonsmoking homes. Frying, smoky cooking events, burning incense and cleaning activities such as sweeping are additional sources of PM. Indoor particulate matter has also been shown to be associated with an increase in asthma symptoms and rescue medication use.
Nitrogen dioxide is a by-product of combustion sources. Household appliances fueled by gas such as gas stoves or kerosene heaters are the major sources of indoor NO 2 . Gas stoves are commonly found in inner city homes. In the seven cities participating in NCICAS, 89% of households had gas stoves. Ventilating with exhaust fans reduces indoor NO 2 levels significantly but the majority of households in NCICAS did not have proper venting. Measurements in inner city households demonstrate high indoor concentrations of NO 2 often exceeding the US Environmental Protection Agency outdoor standard (53 ppb). Asthmatic children exposed to NO 2 indoors are at risk for increased asthma morbidity. NO 2 increases the risk of asthmatic exacerbations following respiratory infections, even at relatively low levels of exposure.
Allergens can be produced from pests (mites, cockroaches, rodents), pets (cats, dogs), plants (pollen) and fungi (mold spores). Cockroach, mice and molds are prevalent in urban areas but there are geographic variations in exposures and sensitization. African American, Mexican American and Puerto Rican children are more likely to be sensitized to cockroach and dust mites.
Exposure to indoor allergens among sensitized asthmatic patients is associated with greater asthma severity and increased healthcare utilization. In sensitized children, indoor exposures to total fungi and to Penicillium species were associated with significant increases in unscheduled visits, even after controlling for outdoor fungal levels. In NCICAS, children exposed and sensitized to cockroach had more days of wheeze, unscheduled doctor visits and hospitalizations compared to those children who were only exposed, only sensitized or neither exposed nor sensitized. In Baltimore, Maryland, among those who were sensitized and exposed to both cockroach and mouse, mouse appeared to be the stronger driver of worse asthma. Cat, cockroach, rodent and house dust mite exposure in children has been associated with asthma exacerbations in a dose dependent fashion.
Asthma guidelines recommend reducing exposure to relevant allergens to reduce inflammation, symptoms and need for medication. A tailored, multifaceted approach to allergen avoidance in the home, based on skin test sensitivity, is emphasized because steps to reduce single allergens have been shown to be largely ineffective. Environmental control represents a financial and practical burden for both patients and society. Successful approaches need to set realistic goals that account for limitations imposed by the inner city setting. Necessary resources may not be available for optimal environmental control. For example, only 38% of homes in NCICAS had functioning vacuum cleaners. Third party payers do not reimburse for supplies and equipment needed by patients to reduce environmental triggers in their homes, nor are visiting homecare workers consistently trained in evaluating homes for triggers and educating patients about household allergen reduction.
Outdoor Environmental Exposures
Higher levels of ambient air pollutants are associated with increased asthma morbidity. Particulate matter (<10 µm [PM 10 ] and <2.5 µm in aerodynamic diameter [PM 2.5 ]) is a collection of mostly inorganic pollutants that has been associated with adverse respiratory effects and exacerbations of asthma. PM 2.5 can penetrate deep into the lung. Increasing asthma morbidity has been observed during a period of declining air pollution. However, populations living in underserved urban communities remain at higher risk because improvement in ambient air quality is not equally distributed among all communities.
Many children living in inner cities live in close proximity to highways and businesses that rely on high volumes of truck traffic. Using the elemental carbon (EC) portion of PM 2.5 as a marker of diesel exhaust emissions, Spira-Cohen et al found increasing risk of adverse respiratory outcomes with increasing exposures to EC concentrations in inner city children with asthma. Using an in vitro model, Wu et al demonstrated that near-roadway PM produced greater inflammatory response than urban background PM. PM induced higher levels of inflammatory cytokines IL-6, IL-8 and TNF-α.
Obesity
There has been a parallel rise in the prevalence of obesity and asthma over the last few decades. Blacks and Hispanics experience higher rates of obesity than whites. Low SES is also associated with higher rates of obesity. Epidemiologic studies show an association between obesity and asthma prevalence and severity. Over one third of children with asthma in a multicenter inner city study were obese compared to 17% of the general population of children in the USAs. Obese children are not only more likely to develop asthma but are more likely to have increased severity resulting in greater healthcare utilization. In a longitudinal study obesity was associated with poorer asthma control in females. One study found that in an urban, predominantly African American population, the effects of indoor PM 2.5 and NO 2 exposure on asthma symptoms were greater in overweight and obese than normal-weight children and adolescents.
Interventions
Many interventions have been developed and implemented in a variety of settings, including EDs, hospitals, clinics, schools and home. The approaches include educational interventions aimed at patients and their families or healthcare providers, case management, and environmental control strategies. The limitations of studies of interventions are that the majority have not been subjected to randomized controlled clinical trials, have small sample sizes, are not culturally sensitive or do not examine the cost-effectiveness. The importance of a proper study design to assess new interventions is underscored by the fact that there is a significant improvement in outcome in children with asthma enrolled in control arms of these trials. Therefore caution needs to be exercised in concluding that an intervention is efficacious when using a pre-post study design.
Therapy
Currently available medications for the management of asthma used according to published guidelines and with good adherence and follow-up are highly effective in controlling asthma symptoms in inner city children. A guideline-based approach improved asthma control in several studies enrolling moderate to severe asthmatics. For example, Figure 33-2 demonstrates that adolescents in a control arm of a study receiving guideline-based care improved quickly and maintained control over the course of the 1-year treatment period. Of interest despite good control of symptoms, children and adolescents continue to experience exacerbations at a high rate, particularly during the fall months. A study by the NIAID Inner-City Asthma Consortium showed a reduction in the frequency of fall asthma exacerbations when omalizumab (an anti-IgE drug) was added to guidelines-directed treatment. The cost of this treatment is high and studies are underway to determine if a shorter course of treatment initiated prior to returning to school prevents the fall exacerbations.
Emergency Department Interventions
Utilization of the ED for children with asthma living in inner cities is high. Previous ED visits are strong predictors of subsequent ED visits. Interventions targeting high-risk children might be expected to have an impact on asthma morbidity because these patients are likely to have severe asthma and poor asthma management skills. A number of strategies have been studied but the results have been conflicting.
A three-part ED-based intervention including asthma screening, viewing an educational video addressing beliefs and a mailed reminder did not improve follow-up or outcomes. A randomized trial by Teach et al evaluated a single comprehensive follow-up visit after ED discharge that included education, initiating controller medications and scheduling a follow-up visit with a primary care provider. The intervention improved asthma treatment adherence, symptom control, quality of life and healthcare use in this population of urban, largely disadvantaged, and minority children. It decreased the rate of unscheduled visits for asthma during the entire 6-month follow-up period. There was no effect of the intervention on follow-up with the primary care provider. A review of studies comparing usual care for asthma to more intensive educational programs concluded that asthma education aimed at children and their caregiver who present to the ED for acute exacerbations resulted in lower risk of future ED visits and hospital admission. It remained unclear as to what type, duration and intensity of educational packages were the most effective in reducing acute care utilization. A Joint Task Force Report reviewing ED interventions recommended among other things that patients seen in the ED should have their asthma characterized and that a follow-up appointment with a primary care physician or asthma specialist be made before leaving the ED and if possible a telephone reminder.
School-Based Interventions
Various strategies have been used in school-based interventions but few have been subjected to randomized controlled clinical trials. Many programs have had trouble fully implementing their plans because school staff, healthcare providers and parents all find it difficult to commit sufficient time and effort to establish new patterns of cooperation. The success of school-based programs for asthma is dependent on a partnership with families and the healthcare system. Individual schools have different capabilities to deal with school health in general and with asthma in particular. The strategy to improve asthma outcomes that is most likely to succeed in a particular school will be dependent on the resources that each component of the partnership can contribute.
Two randomized studies evaluated supervised asthma therapy in urban schools. Both provided medication at no cost. Gerald et al reported improved asthma control among urban school children. In addition to administering medication in school, Halterman et al made guideline-based dosage adjustments and gave a home-based environmental tobacco smoke reduction program for smoke-exposed children. Compared with usual care, the program improved asthma symptoms and decreased exacerbations.
Another strategy is to focus on self-management skills. Evans et al provided self-management education in inner city elementary school children. The program emphasized the child’s responsibility for recognizing symptoms and taking appropriate management steps. Children in treatment schools had increased management skills, fewer symptoms of asthma and improved school performance. A school-based intervention for adolescents used both group and tailored individual sessions and included education for their medical providers. Relative to control subjects, students in the intervention group reported more confidence to manage their asthma, taking more steps to prevent symptoms, greater use of controller medication, and fewer symptoms, acute care visits, hospitalizations and school absences due to asthma.
Although not evaluated in controlled clinical trials, school-based mobile clinics have been used in several cities in the USA. The model attempts to reduce barriers to delivering effective care to underserved children with asthma. The mobile clinics are staffed by specialty trained asthma providers and integrate strategies for case identification, community outreach, continuity of care, structured healthcare encounters and patient tracking. Comparison of pre and post year data for subjects enrolled in the program for at least 1 year revealed reductions in the percentage of patients reporting ED visits, hospitalizations and missed school days.
Provider Targeted Interventions
Despite the findings that adherence to guidelines by providers is suboptimal, there are few rigorously designed trials of interventions aimed at providers in inner cities. A systematic review of provider interventions concluded that decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through healthcare process outcomes.
Training of staff in clinics providing care to inner city minority children coupled with administrative support for change in practice behavior increased the number of patients with asthma receiving continuing care and improved the quality of care they received compared to control clinics. Health outcomes were not reported. The relative contributions of the training program and the strong organizational commitment by the local government health department to the outcomes could not be distinguished. Easy Breathing is a program instituted in primary care clinics serving inner city communities. The program had a positive effect on clinicians’ knowledge and adherence to asthma guidelines as evaluated using a pre-post study design.
The Inner City Asthma Study evaluated a decision support system with feedback to providers. An automated computer program provided information to the child’s primary care physician along with guideline-based treatment recommendations. The computerized algorithm analyzed each child’s current level of symptoms, health care utilization and medication use and, on the basis of National Asthma Education and Prevention Program guidelines, recommended increased treatment, decreased treatment or no change. Children whose primary care physicians received these computerized letters had more follow-up care visits, received increased treatment more rapidly when warranted and had fewer ED visits.
Environmental Interventions
Asthma management guidelines emphasize the need for individualized environmental control measures in the treatment of asthma. In a small double-blind randomized trial in a low-income population, house dust mite mitigation intervention reduced dust mite levels and bronchial responsiveness but not symptoms or quality of life. Attempts to reduce cockroach allergens in the home have had varied success. Integrated pest management, which consists of filling holes with copper mesh, vacuuming and cleaning, and low-toxicity pesticides and traps, can control cockroach infestation. Reduction of cockroach allergen levels is feasible and can be maintained in some, but not all, multifamily dwellings in the inner city.
Limitations in single allergen avoidance trials have directed attention to a multifaceted approach to allergen reduction. Krieger used community health workers to provide in-home environmental assessments, education, support for behavior change and resources. The intervention reduced asthma symptom days and urgent health services use while improving caregiver quality-of-life score. Butz et al randomly assigned children with asthma residing with a smoker to interventions consisting of air cleaners only, air cleaners plus a health coach, or delayed air cleaner (control). The use of air cleaners resulted in a reduction in indoor PM concentrations and an increase in symptom-free days. The intervention did not reduce exposure to secondhand smoke as measured by air nicotine or urine cotinine concentrations.
The Inner City Asthma Study (ICAS) reported on a multifaceted home-based environmental intervention for inner city children with asthma. Intervention was tailored to each patient’s sensitization and environmental risk profile, utilizing a series of modules to reduce home allergen exposure. Individuals who were randomized to environmental intervention demonstrated significantly fewer symptom days during the intervention year and during the year following intervention compared to individuals in the control group. Cost of the intervention ranged from $750 to $1,000 per patient, estimated to cost $27 per symptom-free day. In another multifaceted allergen avoidance study, Carter et al studied the effect of avoidance of dust and cockroach in a group of inner city children with asthma. While there was no overall improvement in the intervention group compared with control, significant reduction in acute visits for asthma was demonstrated for mite-allergic children who had a significant decrease in exposure to mite allergen.
Technology-Based Interventions
There are few rigorously assessed computer-based interventions for asthma. These have had limited success. An educational software program did not produce greater improvement than occurred with review of traditional written materials. A trial of a computer-assisted instructional (CAI) game on asthma symptoms was not effective in improving asthma symptoms. In contrast, a small study found that computer-delivered self-management education used at home scored higher on prevention and treatment strategies and enhanced children’s sense of self-efficacy.
Emerging health information technologies designed to improve patient-physician communication can be used successfully in inner city populations. Among children and adolescents in a low-income, urban population, a text messaging intervention compared with usual care was associated with a modest improvement in the rate of influenza vaccination. Smartphone applications to monitor peak flow or asthma symptoms are available but their use has not been evaluated in controlled clinical trials. The technologies are developing rapidly and have the potential of delivering targeted interventions to individuals. An important barrier to overcome with interventions requiring daily monitoring or daily diaries is decreased compliance with monitoring over time that has been observed in inner city children with asthma.
Multifactorial Interventions
The first phase of the NCICAS showed that a multitude of factors are responsible for asthma morbidity, including adherence, access to care and physician undertreatment. Other risk factors involve the living conditions, social welfare and mental health issues of the family. These risk factors may interfere with the ability of the family to give sufficient attention to the child’s asthma. It also became apparent that asthma management was not the responsibility solely of the physician but of the family as well. For an intervention in the inner city to succeed, it must address a variety of risk factors, not all of which would be the same among individuals.
The asthma counselor intervention program developed by NCICAS used social workers to empower families to increase asthma self-management and to improve their communication with primary care providers. A risk profile was prepared for each child on the basis of assessments of skin test sensitivities, environmental exposures, psychosocial factors, difficulty accessing care, exposure to pets or smoking and other factors. The multifactorial intervention was tailored to each child using specific modules, each of which addressed specific risk factors. This tailored intervention approach was found to be highly effective in reducing asthma symptoms among the children.
Home-based educational interventions may lead to modest short-term improvements in asthma outcomes among inner city children. A home-based intervention using asthma counselors modeled after the NCICAS intervention and culturally adapted for Puerto Rican families found no significant differences in symptom-free days between the intervention and control groups, although significant reductions were observed in symptom-free nights, ED visits and hospitalizations.
A randomized, parallel group, controlled trial found that asthma education led to improved adherence and decreased morbidity compared with usual care. The education consisted of five home visits by trained asthma educators reviewing medications, identifying barriers and discussing beliefs and concerns. Addition of feedback based on objective adherence data did not improve outcomes over education alone. A nurse-led education program in Glasgow, Scotland, for children hospitalized for asthma who were predominantly of lower social class implemented home management training that incorporated written and verbal information and was reinforced with outpatient follow-up appointments and telephone advice. A review suggested that culture-specific education programs for children from minority groups are effective in improving asthma-related outcomes of quality of life, asthma knowledge and rate of asthma exacerbations and asthma control. Thus asthma education programs for children from minority groups with asthma would be more likely to succeed if they were culture specific.
One randomized controlled trial evaluated usual care versus 2-year asthma coach intervention for low-income, Medicaid-covered, African American children. The coaches were two African American women with high school education residing in the same general neighborhoods as the participants. The coach intervention was designed to achieve standardization through a set of key behavioral objectives and a planned schedule of contacts as well as flexibility through a nondirective approach and individualization of key behavioral objectives. The asthma coach intervention achieved lower prevalence of hospitalizations. The intervention did not lead to a decrease in emergency visits that did not require hospitalization. A subsequent study assigned lay workers to coach parents to improve important aspects of care and reduce morbidity in a high-risk population. Coaches were taught the pathogenesis, symptoms and management principles of asthma and how to communicate effectively, provide psychosocial support to parents during times of stress, assess parents’ readiness to engage in targeted management strategies, and promote behavior change. Parental coaching increased asthma monitoring visits, including visits with documented controller medications, but these changes were not associated with fewer ED visits.
Walders et al used an interdisciplinary intervention consisting of a written asthma treatment plan, asthma education, an asthma risk assessment, problem-solving and access to a 24-hour nurse advice line. The intervention group did not show evidence of reduced asthma symptoms or improved measures of quality of life beyond the changes demonstrated by the comparison group. However, the interdisciplinary intervention group had less frequent healthcare utilization for asthma over the course of the 1-year follow-up period.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
