Exposure to home and school environmental triggers and asthma morbidity in Chicago inner-city children.

BACKGROUND: In children, asthma hospitalization rates are highest among those aged 0-4 yr, indicating more acute and/or severe asthma exacerbations in younger children. We investigated the relationship between indoor exposures and three asthma morbidity measures in children of different age groups (0-4, 5-11, and 12 yr of age or older). Identifying the factors leading to asthma morbidity in specific subgroups may lead to a better understanding of the disease and contribute to the development of effective interventions tailored to subgroups. METHODS: Children between 0 and 18 yr of age with asthma were enrolled in an asthma intervention program. At enrollment, hospitalizations, emergency room visits (ED), asthma night symptoms, and exposure to conditions in the child's home and school/daycare related to indoor allergens were collected using standardized questionnaires. Associations of exposure with the three asthma outcomes were estimated using logistic regression, stratified by age group. RESULTS: Of 246 children enrolled, the youngest age group had more hospitalizations in the past year, more ED visits in the past year, and more night awakenings in the past month due to asthma than the oldest two age groups (p = 0.02; p < 0.0001; and p = 0.01, respectively). Overall, more associations of exposures to home triggers were found with hospitalization in children aged 0-11 yr, while classroom triggers were more likely to be associated with hospitalizations among the oldest two groups, 5-18 yr of age. CONCLUSIONS: Examining the relationship of specific environmental exposures with asthma exacerbations and hospitalizations across age group and in different indoor environments warrants further study.

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

OBJECTIVES: Home-based, multifaceted interventions have been effective in reducing asthma morbidity in children. However, identification of independent components that contribute to outcomes and delineating effectiveness by level of asthma symptoms would help to refine the intervention and target appropriate populations. METHODS: A community health educator led asthma intervention implemented in a low-income African-American neighborhood included asthma management education, individually tailored low-cost asthma home trigger remediation, and referrals to social and medical agencies, when appropriate. Changes in asthma morbidity measures were assessed in relation to implementation of individual intervention components using multivariable logistic regression. RESULTS: Among the 218 children who completed the year-long program, there were significant reductions in measures of asthma morbidity, including symptoms, urgent care visits, emergency department (ED) visits, hospitalizations, missed school days, and missed work days for caretakers. We also found significant decreases in the prevalence of many home asthma triggers and improvements in asthma management practices. Improvement in caretaker's ability to manage the child's asthma was associated with reduction in ED visits for asthma and uncontrolled asthma. Specific home interventions, such as repair of water leaks and reduced exposure to plants, dust, clutter and stuffed toys, may be related to reduction in asthma morbidity. CONCLUSIONS: This program was effective in reducing asthma morbidity in low-income African-American children and identified specific interventions as possible areas to target in future projects. Furthermore, the intervention was useful in children with persistent asthma symptoms as well as those with less frequent asthma exacerbations.

Hand hygiene instruction decreases illness-related absenteeism in elementary schools: a prospective cohort study.

BACKGROUND: Illness-related absences have been shown to lead to negative educational and economic outcomes. Both hand washing and hand sanitizer interventions have been shown to be effective in reducing illness-related absences. However, while the importance of hand hygiene in schools is clear, the role of instruction in use is less obvious. The purpose of this study was to compare absenteeism rates among elementary students given access to hand hygiene facilities versus students given both access and short repetitive instruction in use, particularly during influenza season when illness-related absences are at a peak. METHODS: A hand hygiene intervention was implemented from October to May during the 2009/2010 academic year, including peak flu season, in two Chicago Public Elementary Schools among students grades pre-kindergarten to eighth grade (ages 4-14). Classrooms were systematically assigned to an intervention or control group by grade (cluster design). Hand hygiene facilities (sanitizer and soap) were made available to all students. Students in the intervention group also received short repetitive instruction in hand hygiene every 2 months. Only absences as a result of respiratory or gastrointestinal illness were used to establish illness-related absenteeism rates. Percent absent days were calculated and bivariate analyses were performed to compare percent absent days among students given access to hand hygiene facilities versus students given both access and instruction. Prior to the intervention, teachers' perceptions of students' hand hygiene were also evaluated. Teacher perceptions were analysed to describe attitudes and beliefs. RESULTS: Data were collected and analysed for 773 students reporting 1,886 absences during the study period (1.73% of total school days). Both the percent total absent days and percent illness-related absent days were significantly lower in the group receiving short instruction during flu season (P = 0.002, P < 0.001, respectively). This difference peaked during the influenza season (when intervention began) and declined in the following months. Teachers (n = 23) agreed that hand hygiene is not performed properly among students and reported time constraints as a barrier to frequent hand washing. CONCLUSIONS: Adding hand hygiene instruction to existing hand hygiene practices improved attendance at public elementary schools during the flu season. Standardized and brief repetitive instruction in hand hygiene holds potential to significantly reduce absenteeism.

Evaluation of the Fight Asthma Now (FAN) program to improve asthma knowledge in urban youth and teenagers.

BACKGROUND: School-based asthma education programs targeting disadvantaged youth and teens with asthma are lacking. OBJECTIVES: To assess the impact of the Fight Asthma Now (FAN) educational program among 2 populations of predominantly low-income minority students: youth (3(rd)-6(th) graders) and teens (7(th)-8(th) graders). METHODS: Chicago-area elementary schools were invited to participate in this stratified 2-arm study. Eligible schools were assigned to participate either in the intervention or in the control arm. Within each participating school, eligible students were recruited and grouped (stratified by grade and age) to form teen or youth classes. Participants completed a pre- and post-intervention asthma knowledge questionnaire and observation for spacer technique competency. The treatment group received the FAN curriculum between the evaluations. RESULTS: A sample of 26 low-income, predominantly minority-serving schools was recruited. Most participating schools were randomized in a 3:1 ratio to form 25 youth classes (19 intervention and 6 control group) and 16 teen classes (11 intervention and 5 control group), resulting in 275 vs 69 youth and 141 vs 51 teens in the intervention and control groups, respectively. Stratified analyses were performed, and clustering within the school and class was taken into consideration in analyses. Multilevel models adjusting for school, class, ethnicity, sex, and pretest score indicate that the FAN intervention significantly increased both knowledge and spacer competency test scores, among both the youth and teen participants (P = .011 with respect to knowledge score among teen students, P < .0001 for all other cases). CONCLUSIONS: This study suggests that FAN significantly increases asthma knowledge and spacer technique competency within this high-risk population.

Desired attributes and skills of program managers in translation of evidence-based interventions.

Successful chronic disease project management, especially of multiyear initiatives using evidence-based interventions (EBIs), is of great importance to funders, health care decision makers, and researchers, particularly in light of limited funding. However, a gap in knowledge may exist regarding which attributes and skills are most desirable in a program manager to help him or her ensure successful implementation of EBIs. Although some literature examines the dynamics contributing to the success of community coalitions, public health leadership, and community health education, there is minimal literature exploring the significance of a program manager's role in the conceptualization, implementation, and sustainability of initiatives to improve patient and community health. The authors present their experiences as participants in a large-scale asthma initiative implemented in priority communities, as well as results of a survey distributed among all personnel of the program sites. The survey aimed to assess the key skills and attributes, in addition to contextual factors, that contribute to the strength of a program manager overseeing EBIs in asthma initiatives. The results suggest that certain attributes and skills are desirable in recruiting and hiring of a program manager, especially when augmented by ongoing skill-building training, and can help ensure program and research success.

Community-based care coordination: practical applications for childhood asthma.

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

The role of partnerships in addressing childhood asthma: the experiences of the Merck Childhood Asthma Network, Inc. (MCAN) initiative.

Partnerships have taken on added importance in recent years because of their critical role in addressing complex public health problems and translating evidence-based practices to real-world settings. The Merck Childhood Asthma Network, Inc. initiative recognized the importance of partnerships in achieving the program's goals. In this article, case studies of the five Merck Childhood Asthma Network program sites describe the role of partnerships in the development and evolution of the program and its interventions. Three key factors contributed to the success of the partnerships: having common organizational goals, considering context in the selection and engagement of partners, and ensuring that each partnership benefited from the alliance. Over the 4-year program period, all five partnerships evolved, matured, and had an established goal to maintain collaboration.

Balancing "fidelity" and community context in the adaptation of asthma evidence-based interventions in the "real world".

The Merck Childhood Asthma Network (MCAN) initiative selected five sites (New York City, Puerto Rico, Chicago, Los Angeles, and Philadelphia) to engage in translational research to adapt evidence-based interventions (EBIs) to improve childhood asthma outcomes. The authors summarize the sites' experience by describing criteria defining the fidelity of translation, community contextual factors serving as barriers or enablers to fidelity, types of adaptation conducted, and strategies used to balance contextual factors and fidelity in developing a "best fit" for EBIs in the community. A conceptual model captures important structural and process-related factors and helps frame lessons learned. Site implementers and intervention developers reached consensus on qualitative rankings of the levels of fidelity of implementation for each of the EBI core components: low fidelity, adaptation (major vs. minor), or high fidelity. MCAN sites were successful in adapting core EBI components based on their understanding of structural and other contextual barriers and enhancers in their communities. Although the sites varied regarding both the EBI components they implemented and their respective levels of fidelity, all sites observed improvement in asthma outcomes. Our collective experiences of adapting and implementing asthma EBIs highlight many of the factors affecting translation of evidenced-based approaches to chronic disease management in real community settings.

The state of pediatric asthma in Chicago's Humboldt Park: a community-based study in two local elementary schools.

BACKGROUND: Pediatric asthma is a serious public health problem in Chicago and has been designated a high priority concern by residents of Chicago's Humboldt Park, a diverse community area with a large number of Puerto Rican, African American, and Mexican American families. METHODS: In May 2009, following the principles of community-based participatory research, a cross-sectional asthma screening survey was administered to adult caregivers of children attending two Humboldt Park elementary schools. Data were analyzed to determine the prevalence of diagnosed and probable asthma as well as the degree of asthma control among affected children; associations between asthma outcomes and mutable triggers were evaluated. RESULTS: Surveys from 494 children were evaluated. Physician-diagnosed asthma was reported for 24.9% of children and probable asthma identified in an additional 16.2% of children. Asthma was poorly or moderately controlled in 60.0% of diagnosed children. Smoking occurred inside 25.0% of households and 75.0% of caregivers reported idling of vehicles in their community. Report of general stress among caregivers, stress due to community crime, and/or an inability to cope with everyday life were significantly and positively associated with poor asthma morbidity and control among affected children. CONCLUSIONS: Despite high prevalence rates and poor asthma morbidity and control in Humboldt Park, the association of these measures with mutable variables is promising. A community-based asthma intervention to address the issues identified in this study is needed to affect positive change.