Randomized trial of a portable HEPA air cleaner intervention to reduce asthma morbidity among Latino children in an agricultural community.

BACKGROUND: Data on pediatric asthma morbidity and effective environmental interventions in U.S. agricultural settings are few. We evaluated the effectiveness of HEPA air cleaners on asthma morbidity among a cohort of rural Latino children. METHODS: Seventy-five children with poorly controlled asthma and living in non-smoking homes were randomly assigned to asthma education alone or along with HEPA air cleaners placed in their sleeping area and home living room. The Asthma Control Test (ACT) score, asthma symptoms in prior 2 weeks, unplanned clinical utilization, creatinine-adjusted urinary leukotriene E4 (uLTE4 [ng/mg]), and additional secondary outcomes were evaluated at baseline, six, and 12 months. Group differences were assessed using multivariable-adjusted generalized estimating equations. Incident rate ratios of ever experiencing the metrics of poorer asthma health during follow-up (suboptimal asthma management) were estimated using Poisson regression models in secondary analysis. RESULTS: Mean child age was 9.2 and 8.6 years in intervention and control groups, respectively, and two-thirds of participants were male. Primary analysis of repeated measures of ACT score did not differ between groups (HEPA group mean change compared to controls 10% [95% CI: - 12-39%]). A suggestion of greater decrease in uLTE4 (ng/mg creatinine) was observed (- 10% [95% CI: - 20 -1%]). Secondary analysis showed children with HEPAs were less likely to have an ACT score meeting a clinically defined cutoff for poorly controlled asthma using repeated measures (IRR: 0.45 [95% CI: 0.21-0.97]). In Poisson models, intervention participants had reduced risk of ever meeting this cutoff (IRR: 0.43 [95% CI: 0.21-0.89]), ever having symptoms in the past 2 weeks (IRR: 0.71 [95% CI: 0.52-0.98]), and lower risk of any unplanned clinical utilization (IRR: 0.35 [95% CI: 0.13-0.94]) compared to control participants. DISCUSSION: The HAPI study showed generally improved outcomes among children in the HEPA air cleaner group. However, primary analyses did not meet statistical significance and many outcomes were subjective (self-report) in this unblinded study, so findings must be interpreted cautiously. HEPA air cleaners may provide additional benefit for child asthma health where traditional asthmagens (traffic, tobacco smoke) are not prominent factors, but larger studies with more statistical power and blinded designs are needed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04919915 . Date of retrospective registration: May 19, 2021.

Quantifying the Distribution of Environmental Health Threats and Hazards in Washington State Using a Cumulative Environmental Inequality Index.

Background: Environmental racism, community stressors, and age-related susceptibility play a significant role in environmental inequality. The goal of this article was to use an inequality index (II) to assess the level of equality in environmental threats and hazards based on race, poverty, and age in Washington State. Methods: Using the Washington Environmental Health Disparities Map, we quantified the level of disproportionate burdens on communities with greater populations of people of color, people in poverty, children younger than 5, and people older than 65 using 3 cumulative environmental indices and 10 individual environmental indicators. Results: Census tracts with a higher proportion of people of color and those with people living below 185% federal poverty levels were found to be disproportionately burdened by environmental threats (II = -0.175 and II = -0.167, respectively, p < 0.001). Individual environmental indicators were found to disproportionately burden communities of color and low-income communities. Children younger than 5 were also disproportionately burdened by cumulative environmental indices (II = -0.076, p < 0.001) and individual indicators. Our analysis did not show disproportionate burden of environmental health threats based on the proportion of people older than 65 (II = 0.124, p < 0.001). Discussion: The disproportionate burden of the cumulative environmental threats on communities of color and low-income communities in this study corroborates similar analyses. These findings can be applied in policy and regulatory actions to correct the distributive environmental disparities. Conclusion: We found much higher burdens among historically marginalized communities and children who are more susceptible to environmental threats and hazards.

Effectiveness of portable HEPA air cleaners on reducing indoor endotoxin, PM10, and coarse particulate matter in an agricultural cohort of children with asthma: A randomized intervention trial.

We conducted a randomized trial of portable HEPA air cleaners in the homes of children age 6-12 years with asthma in the Yakima Valley, Washington. All families received asthma education while intervention families also received two HEPA cleaners (child's bedroom, living room). We collected 14-day integrated samples of endotoxin in settled dust and PM10 and PM10-2.5 in the air of the children's bedrooms at baseline and one-year follow-up, and used linear regression to compare follow-up levels, adjusting for baseline. Seventy-one families (36 HEPA, 35 control) completed the study. Baseline geometric mean (GSD) endotoxin loadings were 1565 (6.3) EU/m2 and 2110 (4.9) EU/m2 , respectively, in HEPA vs. control homes while PM10 and PM10-2.5 were 22.5 (1.9) µg/m3 and 9.5 (2.9) µg/m3 , respectively, in HEPA homes, and 19.8 (1.8) µg/m3 and 7.7 (2.0) µg/m3 , respectively, in control homes. At follow-up, HEPA families had 46% lower (95% CI, 31%-57%) PM10 on average than control families, consistent with prior studies. In the best-fit heterogeneous slopes model, HEPA families had 49% (95% CI, 6%-110%) and 89% lower (95% CI, 28%-177%) PM10-2.5 at follow-up, respectively, at 50th and 75th percentile baseline concentrations. Endotoxin loadings did not differ significantly at follow-up (4% lower, HEPA homes; 95% CI, -87% to 50%).

Health workers' perspectives of a mobile health tool to improve diagnosis and management of paediatric acute respiratory illnesses in Uganda: a qualitative study.

OBJECTIVES: Mobile health tools have potential to improve the diagnosis and management of acute lower respiratory illnesses (ALRI), a leading cause of paediatric mortality worldwide. The objectives were to evaluate health workers' perceptions of acceptability, usability and feasibility of Acute Lower Respiratory Illness Treatment and Evaluation (ALRITE), a novel mobile health tool to help frontline health workers diagnose, treat and provide education about ALRI in children <5 years. DESIGN: A qualitative study including semistructured interviews with health facility administrators and focus groups with primary care health workers. SETTING: Two federally funded Ugandan primary care health facilities, one peri-urban and one rural. PARTICIPANTS: We enrolled 3 health administrators and 28 health workers (clinical officers and nurses). INTERVENTION: The ALRITE smartphone application was developed to help frontline health workers adhere to ALRI guidelines and differentiate wheezing illnesses from pneumonia in children under 5 years of age. ALRITE contains a simple decision tree, a partially automated respiratory rate counter, educational videos and an adapted respiratory assessment score to determine bronchodilator responsiveness. We performed a demonstration of ALRITE for participants at the beginning of interviews and focus groups. No participant had used ALRITE prior. RESULTS: Themes impacting the potential implementation of ALRITE were organised using individual-level, clinic-level and health-system level determinants. Individual-level determinants were acceptability and perceived benefit, usability, provider needs and provider-patient relationship. Clinic-level determinants were limited resources and integration within the health centre. Systems-level determinants included medication shortages and stakeholder engagement. CONCLUSIONS: Incorporation of these themes will ready ALRITE for field testing. Early engagement of end users provides insights critical to the development of tailored mHealth decision support tools.

Effectiveness of portable HEPA air cleaners on reducing indoor PM2.5 and NH3 in an agricultural cohort of children with asthma: A randomized intervention trial.

We conducted a randomized trial of portable HEPA air cleaners with pre-filters designed to also reduce NH3 in non-smoking homes of children age 6-12 with asthma in Yakima Valley (Washington, USA). Participants were recruited through the Yakima Valley Farm Workers Clinic asthma education program. All participants received education on home triggers while intervention families additionally received two HEPA cleaners (child's sleeping area, main living area). Fourteen-day integrated samples of PM2.5 and NH3 were measured at baseline and one-year follow-up. We fit ANCOVA models to compare follow-up concentrations in HEPA vs control homes, adjusting for baseline concentrations. Seventy-one households (36 HEPA, 35 control) completed the study. Most were single-family homes, with electric heat and stove, A/C, dogs/cats, and mean (SD) 5.3 (1.8) occupants. In the sleeping area, baseline geometric mean (GSD) PM2.5 was 10.7 (2.3) µg/m3 (HEPA) vs 11.2 (1.9) µg/m3 (control); in the living area, it was 12.5 (2.3) µg/m3 (HEPA) vs 13.6 (1.9) µg/m3 (control). Baseline sleeping area NH3 was 62.4 (1.6) µg/m3 (HEPA) vs 65.2 (1.8) µg/m3 (control). At follow-up, HEPA families had 60% (95% CI, 41%-72%; p < .0001) and 42% (19%-58%; p = .002) lower sleeping and living area PM2.5 , respectively, consistent with prior studies. NH3 reductions were not observed.

Community-Level Factors Associated with COVID-19 Cases and Testing Equity in King County, Washington.

Individual-level Coronavirus Disease 2019 (COVID-19) case data suggest that certain populations may be more impacted by the pandemic. However, few studies have considered the communities from which positive cases are prevalent, and the variations in testing rates between communities. In this study, we assessed community factors that were associated with COVID-19 testing and test positivity at the census tract level for the Seattle, King County, Washington region at the summer peak of infection in July 2020. Multivariate Poisson regression was used to estimate confirmed case counts, adjusted for testing numbers, which were associated with socioeconomic status (SES) indicators such as poverty, educational attainment, transportation cost, as well as with communities with high proportions of people of color. Multivariate models were also used to examine factors associated with testing rates, and found disparities in testing for communities of color and communities with transportation cost barriers. These results demonstrate the ability to identify tract-level indicators of COVID-19 risk and specific communities that are most vulnerable to COVID-19 infection, as well as highlight the ongoing need to ensure access to disease control resources, including information and education, testing, and future vaccination programs in low-SES and highly diverse communities.

The home air in agriculture pediatric intervention (HAPI) trial: Rationale and methods.

BACKGROUND: Data addressing air quality effects on children with asthma in rural U.S. communities are rare. Our community engaged research partnership previously demonstrated associations between neighborhood NH3 and ambient PM2.5 and asthma in the agricultural lower Yakima Valley of Washington. As a next step, the partnership desired an intervention approach to address concerns about pediatric asthma in this largely Latino immigrant, farm worker community. OBJECTIVE: The Home Air in Agriculture Pediatric Intervention (HAPI) sought to examine the effectiveness of enrichment of an existing asthma education program with portable high-efficiency particulate air (HEPA) cleaners designed to reduce PM2.5 and NH3. We investigated the effect of this enriched approach on these exposures and asthma health measures. DESIGN: We randomized children with poorly controlled asthma to a control arm (current asthma education program) or an intervention arm (current asthma education program + placement of two indoor air cleaners in the family's home). Outcomes included (1) 14-day integrated samples of indoor air contaminants (PM2.5 and NH3) at baseline and one-year follow-up and (2) child asthma health metrics at baseline, midpoint (4-6 months) and one-year follow-up. These included the Asthma Control Test, symptoms days, clinical utilization, oral corticosteroid use, pulmonary function, fractional exhaled nitric oxide, and urinary leukotriene E4 concentration. DISCUSSION: To our knowledge, this is the first randomized HEPA cleaner intervention designed to assess NH3 as well as PM2.5 and to evaluate health outcomes of children with asthma in an agricultural region.

Listening to Consumer Perspectives to Inform Addictions and Housing-Related Practice and Research.

The study, funded by the Northwest Health Foundation of Portland, Oregon and the National Institute on Drug Abuse (NIDA), was conducted as part of the HEARTH collaborative (Housing, Employment and Recovery Together for Health). HEARTH, established in 2010, is a community-academic partnership involving partners from Portland State University (PSU), Oregon Health and Science University (OHSU), and Central City Concern (CCC). Using the approaches of community-based participatory research (CBPR), these diverse stakeholders collaborated to co-develop research of direct relevance to the local community and to national academic and policy communities. This study employed qualitative methods and community-based participatory research principles to solicit personal experiences with housing, employment, and recovery programs. We recruited interview participants via CCC-operated housing programs, including Alcohol and Drug Free Community Housing (ADFC), family housing, transitional housing, and non-ADFC (low barrier) housing units. The manuscript presents interview themes based on the five broad categories of interview questions: housing, employment programs, recovery programs, definitions of recovery, and definitions of success. Co-authors describe recommendations for practice and research protocol based on our findings. Our results highlight the importance of involving consumers in the development, data collection, and analysis of research, and present the unique perspectives of those who experience homelessness, recovery, and the programs designed to assist them.

Findings from a community-based participatory prevention research intervention designed to increase social capital in Latino and African American communities.

A community-based participatory research intervention, Poder es Salud/Power for Health, employed Community Health Workers who used popular education to identify and address health disparities in Latino and African American communities in a metropolitan area in the United States. We assessed participants' social capital, self-rated health, and depressive symptoms at baseline and the end of the intervention. Social support and self-rated health improved while depressive symptoms decreased. Public health interventions involving diverse communities that are designed to build upon assets, such as existing levels of social capital, may improve health in those communities.

Neighborhood design and active aging.

This qualitative analysis of focus groups describes how neighborhood design encourages active aging. Nine focus groups were conducted in 2002 and 2003 with residents (N=60) aged 55 and over living in Portland, OR, USA. Content analysis revealed that local shopping and services, traffic and pedestrian infrastructure, neighborhood attractiveness, and public transportation influence activity among older adults. This information will be useful for making policy recommendations relating to land use planning and transportation, to assist in senior-friendly developments and neighborhood improvements, and to design effective senior health interventions with an emphasis on neighborhood design influences.

Developing a reliable Senior Walking Environmental Assessment Tool.

BACKGROUND: Research of the effects of the built environment on physical activity often excludes certain segments of the population. The senior population, one segment perhaps most influenced by the physical features of an environment, has been understudied. Developing reliable measures of the environment is important to increase our understanding of the environmental effects on physical activity among seniors. METHODS: A review of urban planning and health literature helped identify important concepts and theories that were used to inform the development of the Senior Walking Environmental Assessment Tool (SWEAT). Urban planning and health research professionals were consulted and provided feedback on the tool. A total of 355 neighborhood segments were assessed using SWEAT. Thirty-six neighborhood segments were assessed for inter-rater reliability. RESULTS: Overall, raters exhibited good-to-excellent agreement on most items included in SWEAT. Items assessing buildings and destinations were less reliable than other categories. CONCLUSIONS: The development of a reliable senior-specific environmental measurement of detailed street level environmental features that may influence walking among seniors is important to advance this research and engage communities to consider simple environmental changes that encourage walking among seniors.

Building on leadership and social capital to create change in 2 urban communities.

There has been an appeal to reduce health inequities by increasing community involvement and social capital. Poder es Salud/Power for Health is a community-based participatory prevention research project that seeks to address health disparities in the African American and Latino communities by enhancing community-level social capital. We provide specific examples of how this intervention uses community health workers and popular education to reduce language and cultural barriers and enhance community social capital. Although the communities share fundamental challenges related to health disparities, the ways in which the Latino and African American communities identify health concerns, create solutions, and think about social capital vary. Members of the project are working together to identify opportunities for cross-cultural collaboration.

The relationship between social support, stress, and health among women on Detroit's East Side.

A conceptual model of the stress process has been useful in examining relationships between numerous social determinants (e.g., chronic stress), protective factors (e.g., social support), and health status. In this article, the authors examine multiple sources of chronic stress, instrumental and emotional support, and health outcomes among a random sample (N = 679) of predominantly low-income African American women who reside on Detroit's east side. The findings suggest that a number of chronic stressors have an impact on depressive symptoms and general health and that even though instrumental and emotional support each have a significant effect over and above the effects of the stressors, when both are included in the model, instrumental support, and not emotional support, remains as a significant predictor of health outcomes. These findings suggest the need for health education interventions and policy strategies that strengthen social support and aim at macro-level changes necessary to reduce chronic stressful conditions.