The four stages of neighborhood trust: Classic grounded theory.

INTRODUCTION: Neighborhoods are often overlooked as a determinant of health. Among recent research, the focus on "place-based effects," due to prolonged residential environmental exposure, has been of particular interest. These studies' purpose is to identify and examine how a healthy neighborhood is intentionally created to describe a transferable process-driven theory. METHOD: A classic grounded theory approach was used in these studies. Data sources include individual in-depth interviews, historical documents, and a member-checking focus group, collected over 3-years. RESULTS: Analysis generated the Four Stages of Neighborhood Trust Model, which is nested within the context of perceived neighborhood safety. The theory outlines a social process of four stages of neighborhood trust: (a) rules-based agreements, (b) shared values, (c) cooperation, and (d) neighborhood belonging. CONCLUSIONS: We present the development of a process-driven theory that may be useful for public health nurses as they engage neighborhoods in health promotion activities. The stage of trust development will aid the nurse in identifying what is needed to move to the next stage in a healthy neighborhood process.

Feasibility and acceptability of home monitoring with portable spirometry in young adults with asthma.

OBJECTIVE: Self-monitoring asthma control is a key component of asthma management. Few studies have reported usability and acceptability of portable spirometry among young adults with asthma. Portable spirometry offers a practical solution to monitoring airway narrowing at home. The purpose of this paper was to determine if self-administered spirometry is feasible and acceptable in young adults with asthma and whether regular monitoring resulted in improved airway function as measured by forced expiratory volume in one second (FEV1). METHODS: Sixty-seven young adults (18-26 years) with self-reported asthma participated in a clinical trial during wildfire season which measured FEV1 as an outcome measure. Data was collected at baseline, week 4, and week 8 using a portable spirometer linked to a smartphone application. A subset of intervention participants completed spirometry twice daily. Acceptability of self-administered spirometry was evaluated after the trial among participants that volunteered to submit a survey and be interviewed. RESULTS: At baseline, all 67 participants (100.0%) completed their scheduled spirometry readings which declined to 94.0% (n = 63) at week 4 and 86.6% (n = 58) at week 8. Daily readings were completed 83.2% of the time in the mornings and 84.3% of the time in the evenings. Mean FEV1 values were lower than predicted values, but above the lower limit of expected. FEV1 remained steady throughout the study period. Over two-thirds of participants used the notes feature in the application and described symptoms, asthma triggers, mitigating actions and test-taking issues. CONCLUSIONS: Young adults in our sample were highly compliant with regular, self-administered spirometry.

Assessing community response to wildfire smoke: A multimethod study using social media.

OBJECTIVE: The purpose of this study was to assess health-related responses to wildfire smoke on social media. We examined whether seasonal wildfire smoke is an active topic on Twitter, the correlation between fine particulate matter (PM2.5 ) and Twitter search terms, and dimensions of community-level expression to wildfire smoke through tweets. DESIGN: Search terms were identified using a conceptual model developed and refined by healthcare providers and public health experts. Wildfire-related tweets were downloaded from Twitter users in Spokane, Washington during the 2017 and 2018 wildfire seasons. PM2.5 data were correlated with the search terms. A subset of tweets was deductively and then inductively coded to identify perceptions and behavioral responses to wildfire smoke. RESULTS: Seasonal wildfire smoke is an active topic on Twitter. The term "smoke" was strongly correlated with poor air quality and "unhealthy" was moderately correlated. Deductive analyses revealed a multidimensional response to wildfire smoke. Inductive analysis identified new areas of concern, such as pet and animal health. CONCLUSIONS: Social media is a lens through which public health professionals can assess and respond to local community needs. Findings will be used to broaden the conceptual model, enhance ongoing surveillance of community-identified health risks, and communicate protective actions.

Promoting risk reduction among young adults with asthma during wildfire smoke: A feasibility study.

OBJECTIVE(S): This study explored the feasibility, acceptability, preliminary impact, and functionality of two risk reduction mobile application (app) interventions on asthma outcomes as compared to a control arm during wildfire season. DESIGN: Three-arm, 8-week randomized clinical trial. SAMPLE: Sixty-seven young adults with asthma were enrolled. MEASUREMENTS: The Asthma Control Test, forced expiratory volume in one second (FEV1 ) and the System Usability Scale were measured at baseline, 4, and 8 weeks. The Research Attitude Scale was administered at 8 weeks. Twenty participants from the two intervention arms completed an optional survey and six were interviewed after completing the study. INTERVENTION: Both intervention arms could access Smoke Sense Urbanova, an app that supports reducing risks from breathing wildfire smoke. The Smoke Sense Urbanova Plus arm also monitored their daily FEV1 , received air quality notifications, and accessed preventive tips and a message board. RESULTS: Most participants agreed the app and spirometer were usable and their privacy and confidentiality were maintained. No adverse events were reported. CONCLUSIONS: Participant-identified recommendations will support intervention refinement and testing. This research supports asthma self-management tools that public health nurses and community health workers can recommend for at-risk populations.

"Is It Good or Bad for the Air?" Latino and Asian Pacific Islander Youth-Led Messaging and Action for Environmental Justice Through Photovoice.

Photovoice is a powerful way to generate youth reflection and social action for health promotion. While the literature offers numerous examples of photovoice studies involving youth, they are most often engaged in taking, dialoguing, and developing phototexts, but not always in the critical next stages of planning what to do with this data, in terms of analyzing and then planning change-related strategic actions. This article describes the ways in which an intergenerational environmental justice project, as part of a larger community-based participatory research program, engaged youth through all stages of a photovoice project. Latino and Asia Pacific Islander adults recruited their own and other youth to conduct a photovoice and air sample data collection, analysis, exhibition, and evaluation activity focused on addressing indoor environmental justice threats from volatile organic chemicals. We offer lessons learned and reflect on the role of intergenerational collaboration to support youth in applying a critical lens for analyzing photovoice data and advocacy for health in their communities. We conclude with implications for photovoice practice and research.

Assessing the value of the Meaningful Use Clinical Summary for patients and families with pediatric asthma.

Electronic clinical summaries are innovations supported by the Electronic Health Record Incentive Program, known as "Meaningful Use" (MU). The MU clinical summary documents the shared understanding of the plan of care for patients and assists families in managing asthma-related health care. The purpose of this analysis was to identify the communicative value of the summaries to patients and families. Readability measurements, content analysis, and descriptive statistics were employed in a review of twenty clinical summaries and compared with provider encounter notes. The average age of the patients from whom we collected clinical summaries was six years old. The average reading level of the summaries was ninth grade. Neither summaries nor health education contained visual images. There was a total of nine different asthma diagnoses. A full list of diagnoses was present in 45% of summaries. The average medications per patient was 5.75, and there were multiple medication changes noted (dosage adjustment, add, discontinued). Allergies, vital signs, and smoking status were reliably reported (99-100%). Provider orders present included medication, follow up, and return to the clinic instructions. The plan of care was replicated on 45% of summaries. There was variable reporting of various asthma guidelines. Opportunities to improve the clinical summary include using plain language to promote readability, action, understanding, and health literacy, training providers to standardize their documentation and include asthma action plans, and configuring EHR settings to ensure diagnoses and plan of care is carried over from provider notes to the summary.

A National Survey Examining Manuscript Dissertation Formats Among Nursing PhD Programs in the United States.

PURPOSE: Among research-focused nursing doctoral (PhD) programs in the United States, the traditional dissertation format has recently given way to a series of publication-ready manuscripts, often bookended by introduction and conclusion chapters. To help programs make decisions about the use of these formats, this study undertook a national survey of programs offering PhDs in nursing. The purpose of this study was to explore the advantages and disadvantages of the traditional format versus manuscript option for dissertations among nursing PhD programs in the United States. DESIGN: Cross-sectional census survey of U.S. nursing PhD programs. METHODS: A web-based survey was administered to all U.S. nursing PhD programs. Respondents indicated formats offered, factors contributing to decisions of which formats to offer, and lessons learned. Descriptive statistics and inductive content analyses were used for analysis. FINDINGS: Of 121 eligible institutions, 79 provided eligible responses (66.7%). The majority (59%) offered both formats; 11% offered the manuscript option only, and 24% offered the traditional format only. Faculty support (or lack thereof) contributed to adoption (or not) of the manuscript option. Respondents' approaches to the manuscript option (e.g., number of papers) and advice are summarized. CONCLUSIONS: Manuscript option dissertations are commonly offered and provide benefits to students and faculty; however, thoughtful implementation is critical. Programs need to agree upon clear expectations and have graduate school support (e.g., formatting). Faculty need mentorship in advising manuscript option students who choose to use this format, and the time and support. Finally, students need additional writing skills that could be provided through coursework or via individual work with mentors. CLINICAL RELEVANCE: As nursing education continues to expand further into doctoral research, programs must examine dissertation formats in order to both prepare future nurse scholars and disseminate nursing research that is critical to improving nursing education, patient care, and clinical practice.

Retest of a Principal Components Analysis of Two Household Environmental Risk Instruments.

Household Risk Perception (HRP) and Self-Efficacy in Environmental Risk Reduction (SEERR) instruments were developed for a public health nurse-delivered intervention designed to reduce home-based, environmental health risks among rural, low-income families. The purpose of this study was to test both instruments in a second low-income population that differed geographically and economically from the original sample. Participants (N = 199) were recruited from the Women, Infants, and Children (WIC) program. Paper and pencil surveys were collected at WIC sites by research-trained student nurses. Exploratory principal components analysis (PCA) was conducted, and comparisons were made to the original PCA for the purpose of data reduction. Instruments showed satisfactory Cronbach alpha values for all components. HRP components were reduced from five to four, which explained 70% of variance. The components were labeled sensed risks, unseen risks, severity of risks, and knowledge. In contrast to the original testing, environmental tobacco smoke (ETS) items was not a separate component of the HRP. The SEERR analysis demonstrated four components explaining 71% of variance, with similar patterns of items as in the first study, including a component on ETS, but some differences in item location. Although low-income populations constituted both samples, differences in demographics and risk exposures may have played a role in component and item locations. Findings provided justification for changing or reducing items, and for tailoring the instruments to population-level risks and behaviors. Although analytic refinement will continue, both instruments advance the measurement of environmental health risk perception and self-efficacy. © 2016 Wiley Periodicals, Inc.

Strengthening Community Capacity for Environmental Health Promotion through Photovoice.

OBJECTIVE(S): The study aims were to: (1) Identify health promoters'; perceptions of housing issues faced by farmworker families in an agricultural community, and (2) Strengthen community capacity to promote healthy and affordable housing. DESIGN AND SAMPLE: Photovoice was used to identify participants'; perceptions about farmworker housing. Thematic analysis was used to analyze participant interviews. Freudenberg's "Community Capacity for Environmental Health Promotion" framework was used to organize activities that contributed to strengthening community capacity. Purposive sampling was used to recruit six bilingual health promoters into the study. MEASURES: A demographic questionnaire was administered to characterize participants. An interview guide was used to inquire about housing conditions and the research process. A tracking tool was used to document capacity-building activities 2 years post data collection. RESULTS: Housing issues faced by farmworker families included housing availability, poor conditions, and invisibility. All dimensions of community capacity were represented. Most occurred on an individual level. CONCLUSIONS: Health promoters identified housing issues and built community capacity to support farmworker housing. Nurses can support housing initiatives by assessing housing status, using data to support healthy housing, supporting health promoter programs in new service delivery models, and leading coalitions to address housing as a social determinant of health.

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

OBJECTIVE: The purpose of this study is to report how photovoice was used to (1) ascertain Mexican-American caregiver perspectives about asthma management, and (2) engage caregivers in dissemination. METHODS: Eleven Mexican-American caregivers of children with asthma were recruited and given cameras to photograph what helped or hindered their ability to care for their child. Participants prioritized which images to share, discussed the images with the group, and wrote accompanying titles and captions in four photovoice sessions. Sessions were in Spanish and occurred in a community setting. Participants presented their work to peers and community members. Identified issues were subsequently categorized by investigators according to the four components of asthma care. RESULTS: Participants prioritized 32 phototexts, the majority of which (n = 20, 63%) reflected activities associated with environmental control. Caregivers highlighted asthma triggers, and suggested ways to maintain indoor air quality (IAQ) through home cleaning. The need for policies that enforce smoking bans in shared housing and public places was identified as an important strategy to improve outdoor air quality. "Education for a Partnership in Asthma Care" was represented in six (19%) phototexts. Five phototexts (16%) represented "Assessment and Monitoring". Only one phototext (3.13%) primarily represented "Medications". CONCLUSIONS: Results support the need for active partnerships between caregivers and providers. Photographs can serve as the basis for reciprocal education between patient and provider, especially in the area of environmental triggers. Provider visits should include assessment, strategies and resources to maximize IAQ. Photovoice facilitates caregivers' ability to advocate for improved asthma management and health equity.

A systematic review of the literature on screening for exercise-induced asthma: considerations for school nurses.

Asthma is a major cause of illness, missed school days, and hospitalization in children. One type of asthma common in children is exercise-induced asthma (EIA). EIA causes airway narrowing with symptoms of cough and shortness of breath during exercise. The purpose of this article is to review the literature relevant to screening children and adolescents for EIA and to inform development of a school nurse-led EIA screening program. A systematic review of EIA screening tests was conducted by searching PUBMED for key terms. Sixty-seven articles were identified; after review only seven met the inclusion criteria. The most common screening test was the 6-min exercise challenge. School-based screening programs have the potential to identify EIA among undiagnosed children and adolescents. School nurses are health professionals with the knowledge and skills necessary to develop successful screening programs in the school setting. Based on results of the literature review, we present implications for developing screening programs in schools to identify children with undiagnosed EIA.

Latina youths' perceptions of children's environmental health risks in an agricultural community.

OBJECTIVES: The objective of this study was to identify Latina youths' perceptions of local assets and concerns related to children's environmental health (EH) in an agricultural community. DESIGN AND SAMPLE: Four photovoice sessions were used to elicit 6 promotores' and 5 middle school students' perspectives on problems and strengths related to "children; environment; and health." MEASURES: Data collection was diverse and included a demographic and evaluation questionnaire, photographs, audio recordings of group photo-sharing sessions, and field notes. RESULTS: Participants identified three themes that reflected group discussion during two photo-sharing sessions: a lack of structured youth activities; poverty and stress; and benefits and detriments of agricultural work. Community assets related to creating a healthy environment for youth were identified and included the clinic, churches, and youth programs. CONCLUSIONS: Findings from this study reinforce that social background and position affect how EH issues are defined and may be addressed. Participant perspectives are valuable to nurses because they offer a lens through which to see the complexities of EH from the viewpoint of those most directly affected. Leadership training and opportunities to serve on coalitions and neighborhood councils are recommended approaches to meaningfully involving youth in environmental justice initiatives.

Agricultural Worker Perspectives on Climate Hazards and Risk Reduction Strategies.

OBJECTIVE: The purpose of this study was to understand the experiences of agricultural workers during periods of heat and wildfire smoke exposure and to support the development and implementation of protective workplace interventions. METHODS: Using community-engaged research and the Center for Disease Control (CDC) framework for policy evaluation, a qualitative descriptive study was conducted with current and former agricultural workers in Central Washington (WA). Twelve participants answered semi-structured questions via interviews or by attending a focus group. Interviews and focus groups were conducted in Spanish, recorded, transcribed, and translated into English; one interview was conducted in English. RESULTS: Using Braun and Clarke's Reflexive Thematic Analysis, five themes were identified among workers from various worksites: 1) Extreme weather and working conditions are becoming increasingly hazardous to worker health, 2) Employers and supervisors lack training and education on current labor laws, and health and safety rules, 3) Employers and supervisors use intimidation and retaliation to ensure productivity and to evoke feelings of replaceability among workers, 4) Workers do not trust regulatory agencies to enforce rules or hold employers accountable, 5) Solutions to climate-driven problems in the agricultural industry need to value worker health and safety, not just productivity. Participants reported experiencing adverse health symptoms related to heat and smoke exposure at work. Workers proposed solutions including improving education, training, and communication, and increased enforcement of existing and forthcoming occupational health and safety rules. CONCLUSION: The agricultural workforce is essential for ensuring a robust food supply and is facing extreme weather events due to climate change. Western states impacted by wildfires and heat are working to develop and implement occupational health and safety rules. Developing effective policies and interventions inclusive of worker perspectives is critical to adapt to a changing climate, retain a stable workforce and promote optimal health.

Association of social vulnerability factors with power outage burden in Washington state: 2018-2021.

Major power outages have risen over the last two decades, largely due to more extreme weather conditions. However, there is a lack of knowledge on the distribution of power outages and its relationship to social vulnerability and co-occurring hazards. We examined the associations between localized outages and social vulnerability factors (demographic characteristics), controlling for environmental factors (weather), in Washington State between 2018-2021. We additionally analyzed the validity of PowerOutage.us data compared to federal datasets. The population included 27 counties served by 14 electric utilities. We developed a continuous measure of daily outage burden using PowerOutage.us data and operationalized social vulnerability using four factors: poverty level, unemployment, disability, and limited English proficiency. We applied zero-altered lognormal generalized additive mixed-effects models to characterize the relationship between social vulnerability and daily power outage burden, controlling for daily minimum temperature, maximum wind speed, and precipitation, from 2018 to 2021 in Washington State. We found that social vulnerability factors have non-linear relationships with outages. Wind and precipitation are consistent drivers of outage occurrence and duration. There are seasonal effects that vary by county-utility area. Both PowerOutage.us and federal datasets have missing and inaccurate outage data. This is the first study evaluating differential exposure to localized outages as related to social vulnerability that has accounted for weather and temporal correlation. There is a lack of transparency into power outage distribution for those most vulnerable to climate impacts, despite known contributions by electric utilities to climate change. For effective public health surveillance of power outages and transparency, outage data should be made available at finer spatial resolution and temporal scales and/or utilities should be required to report differential exposure to power outages for socially vulnerable populations.

The Household Risk Perception instrument and the Self-Efficacy in Environmental Risk Reduction instrument: psychometric testing using principal component analysis.

AIM: To report the psychometric testing of the Household Risk Perception and Self-Efficacy in Environmental Risk Reduction instruments using principal components analysis. BACKGROUND: There are limited instruments available to test household risk perception and self-efficacy related to environmental health behaviours. The Household Risk Perception instrument was developed to measure personal perceptions of household environmental health risks. The Self-Efficacy in Environmental Risk Reduction instrument was designed to measure caregivers' confidence in taking steps to reduce household risks. DESIGN: An exploratory analysis of previous data was undertaken. METHOD: Baseline data from 235 caregivers enrolled in a randomized clinical trial testing a healthy housing intervention were collected between 2006-2009. Principal components analysis was used to determine principal components from measured responses to each instrument. RESULTS: Components were explored and compared to constructs used to design the original instruments. A five-component structure showed the simplest solution and explained 65% of variance in the Household Risk Perception analysis. Cronbach's alpha values indicated satisfactory internal consistency for four of five identified components. Risk perception varied according to available sensory input of the specific risk. A four-component structure explained 64% of the variance in the Self-Efficacy in Environmental Risk Reduction analysis. Cronbach's alpha values were satisfactory. Items mapped to steps in an action-oriented process vs. agent-specific actions. Results from both analyses suggest that environmental tobacco smoke is perceived differently than other household risks. CONCLUSION: Previously, both instruments relied on item reliability and content validity testing. This study provides a basis for further instrument revision and theoretical testing.

Flexible Resources Key to Neighborhood Resilience for Children: A Scoping Review.

Neighborhoods have been the focus of health researchers seeking to develop upstream strategies to mitigate downstream disease development. In recent years, neighborhoods have become a primary target in efforts to promote health and resilience following deleterious social conditions such as the climate crisis, extreme weather events, the global pandemic, and supply chain disruptions. Children are often the most vulnerable populations after experiencing unexpected shocks. To examine and describe conceptually the construct of Neighborhood Resilience, we conducted a comprehensive scoping review using the terms ("resilience" or "resiliency" or "resilient") AND ("neighborhood"), utilizing MEDLINE (through PubMed) and CINAHL (through EBSCOhost) databases, to assess overall neighborhood themes that impact resilience. A total of 57 articles were extracted that met inclusion criteria. Extracted characteristics included study purpose, country of origin, key findings, environmental protective/risk factors. The analysis revealed a positive relationship between neighborhood resource density, neighborhood resiliency, and individual resiliency. This study reports the finding for studies with a population focus of pre-school age and school age children (1.5-18 years of age). Broadly, we identified that the primary goals regarding neighborhood resilience for childhood can be conceptualized as all activities and resources that (a) prevent trauma during childhood development and/or (b) mitigate or heal childhood trauma once it has occurred. This goal conceptually encompasses antecedents that increase protective factors and reduces risk factors for children and their families. This comprehensive look at the literature showed that a neighborhood's ability to build, promote, and maintain resiliency is often largely dependent on the flexible resources (i.e., knowledge, money, power, prestige, and beneficial social connections) that are available.

Allostatic Load Measurement: A Systematic Review of Reviews, Database Inventory, and Considerations for Neighborhood Research.

BACKGROUND: Neighborhoods are critical to understanding how environments influence health outcomes. Prolonged environmental stressors, such as a lack of green spaces and neighborhood socioeconomic disadvantage, have been associated with higher allostatic load levels. Since allostatic load levels experienced earlier in life have stronger associations with mortality risk, neighborhoods may be uniquely suited to monitor and mitigate the impacts of environmental stressors. Researchers often study allostatic load in neighborhoods by utilizing administrative boundaries within publicly accessible databases as proxies for neighborhoods. METHODS: This systematic review of reviews aims to identify commonly used biomarkers in the measurement of allostatic load, compare measurement approaches, inventory databases to study allostatic load, and spotlight considerations referenced in the literature where allostatic load is studied in neighborhoods. The review was conducted using the search term "allostatic load" in the MEDLINE, CINAHL, and PsychINFO databases. The search results were filtered to include reviews. RESULTS: The search returned 499 articles after deduplication. Overall, 18 synthesis reviews met the inclusion criteria and were retained for extraction. The synthesis reviews analyzed represented 238 studies published from 1995 to 2020. The original ten biomarkers were most often used to measure allostatic load. More recently, body mass index and C-reactive protein have additionally been frequently used to measure allostatic load burden. CONCLUSIONS: The scientific contributions of this study are that we have identified a clear gap in geographic considerations when studying allostatic load. The implication of this study is that we have highlighted geographic concepts when conducting neighborhood-level research using administrative databases as a neighborhood proxy and outlined emerging future trends that can enable future study of allostatic load in the neighborhood context.

Effectiveness of a household environmental health intervention delivered by rural public health nurses.

OBJECTIVES: Parents need meaningful and actionable information if they are to reduce household environmental health risks to their children. To address this issue, we tested the effectiveness of a multi-risk social/cognitive intervention on rural low-income parents' (1) environmental health self-efficacy and (2) stage of environmental health precautionary adoption. METHODS: Biomarker (lead, cotinine) and household samples (carbon monoxide, radon, mold/mildew, and drinking water contaminants) were collected from 235 families (399 adults, 441 children) in Montana and Washington states. Families were randomly assigned to intervention or control groups; intervention families received 4 visits from public health nurses who provided tailored information and guidance to parents; controls received usual and customary public health services. RESULTS: At 3 months, the intervention group had significantly higher scores on (1) all 6 risk-specific self-efficacy subscales (P < .01), (2) general environmental health self-efficacy (P < .001), (3) 5 of 6 risk-specific precaution adoption subscales (P < .05), and (4) general environmental health precaution adoption (P < .001). CONCLUSIONS: The intervention yielded significant improvements in both outcomes. This evidence supported the need for a policy discussion addressing the added value that broadbased public health nurse interventions might bring to children's environmental health.

The feasibility and acceptability of a home-visitation, asthma education program in a rural, Latino/a population.

OBJECTIVES: The effectiveness of community health worker-delivered interventions to decrease environmental triggers for asthma in the home has been well documented in urban populations, but has had little evaluation in rural, Latino/a families. The purpose of this study was to evaluate the feasibility and acceptability of a home-visitation intervention designed to decrease environmental triggers for pediatric asthma in rural, Latino/a families. METHODS: Data from a large community health clinic's pediatric asthma program (2002, 2003, 2004, 2005, 2006) were used to retrospectively explore associations between program participation and asthma-related health outcomes. Demographic data were collected on 866 patients. Behavioral outcomes were evaluated in 374 participants. A medical record abstraction was conducted in a subsample of 400 patients to evaluate asthma-related urgent care use. Nonparametric tests were used to compare outcomes before and after the intervention. Demographic attributes associated with program participation were examined using logistic regression. RESULTS: Most (91%) participants were Hispanic, and 61% of participants' caregivers were either seasonal or migrant farmworkers. Over half (61%) of the participants did not complete the full intervention. A statistically significant improvement was found in caregivers' abilities to manage asthma medications and adopt behaviors to decrease triggers inside the home. Behaviors related to decreasing outside triggers did not significantly change. Asthma-related urgent care use significantly decreased; however, there was no association between intervention dose and a decrease in urgent care use. Demographic attributes were generally not associated with program completion, having baseline and exit data on intermediate outcomes, and/or inclusion in the chart review. CONCLUSIONS: Results suggest that the asthma intervention helped caregivers improve the air quality in their homes and reduce urgent care admissions among pediatric participants. The intervention dose may be less important than taking part in an intervention to the extent feasible or desired by the family. Findings suggest that policy-level interventions need to address reimbursement for home visitation and environmental exposures that are beyond caregiver control, such as support for healthy and affordable housing in farmworker communities.