SEATTLE—The prevalence of asthma among children is increasing across the country, but it affects inner-city families to an excessive degree. Often, these families do not have ready access to health care providers, prescription medication, or education about asthma management. Furthermore, children living in inner-city homes are often exposed to multiple allergens, which can exacerbate their symptoms.

Currently, researchers are looking at ways of reducing the asthma burden in inner-city communities by using cost-effective, sustainable, and most of all, practical methods. At the 2003 annual meeting of the American Thoracic Society, held in Seattle, speakers described a number of strategies that are proving to be effective in modifying the home environments of inner-city children with asthma. The research presented at the meeting focused on methods for limiting or eradicating dust, cockroach, and mouse allergens in the home, as well as approaches for reducing children’s exposure to environmental tobacco smoke (ETS).[1]

INTENSIVE CLEANING AND PEST MANAGEMENT

Two studies, one in Tucson and one in New York City, used high-intensity interventions performed by the researchers to modify homes of children with asthma. Only one of these studies produced positive results. In addition, both were hampered by the fact that they involved a lot of physical work inside the homes on the part of the intervention teams, without teaching families how to maintain the effects of the intervention after the study.

In the Tucson study, the intervention centered on the child’s bedroom, to create a “safe sleeping zone.” The study found that reducing the allergen load in the child’s bedroom can significantly improve asthma symptoms. The New York City study used a three-day intensive cleaning and integrated pest management strategy in an attempt to reduce allergen levels and, as a result, allergic sensitization. However, at the end of the study, there was no evidence of benefit.

COMMUNITY ACTION AGAINST ASTHMA

If high-intensity physical interventions are either ineffective or impractical, what other options exist? Community-based participatory research (CBPR) directly involves residents of the communities in which the study participants live. This approach appears to affect asthma outcomes.

“It is important to take local factors into account when designing solutions,” said Toby C. Lewis, MD, MPH, a pediatric pulmonologist at the University of Michigan Health System in Ann Arbor. “We need to take a broad view of the factors that influence health and tailor the interventions to the concerns and culture of the participants,” she said, adding that there is “considerable expertise among community members, and we need to draw on this when deciding how to attack [the asthma] problem.”

Dr. Lewis was involved in the Community Action Against Asthma project, a CBPR study that also used household interventions to reduce environmental triggers for asthma. Researchers from the University of Michigan and community groups in Detroit worked together from the study’s beginning.

Representatives from the community met with the study team monthly and had input on the wording of surveys, design of protocols, recruitment strategies, and incentives. These representatives pointed out the need to use community members as field workers—both to implement the intervention and collect data. They also recommended that all asthma/allergy testing be done in a community setting rather than at the university, and that all of the findings be shared with the participants.

According to Dr. Lewis, the study team’s premise was “that a household-level environmental intervention, … tailored to family needs and provided by lay community outreach workers, can modify the physical environment and improve asthma health-related outcomes.”

About 300 families with at least one child age 6 to 11 who had probable or known asthma were enrolled. Children were randomized to one of two groups. Group 1 received the intervention immediately, and group 2 received it a year later.

Community environmental specialists went to homes and spoke to families. During the first visit, they provided specific asthma information and learned what the pressing issues for the family were. If necessary, they provided referrals for social service agencies to help address these issues—which also helped to build a rapport with the family, noted Dr. Lewis.

The environmental specialists talked with the families about the results of their home assessment, the child’s skin test sensitivity, and the allergen levels in the home. They worked with the families to determine which allergens they would work on first. High-efficiency particulate air (HEPA) vacuums were given to each household, along with allergen mattress covers and cleaning supplies. Specialists visited each family about nine times during the first year.

Although this study’s findings have not yet been published, preliminary results indicate that symptom frequency and peak flow improved significantly during the intervention year. The social support and advocacy provided by community workers, said Dr. Lewis, allowed caregivers to focus on asthma risk factors and prevention strategies—and consequently to help their children’s symptoms.

HEALTHY HOMES

Another CBPR program—the Healthy Homes Project in Seattle—used community health workers as an intervention in inner-city communities. The surprising finding was that an effective intervention does not have to be cost prohibitive.

James W. Krieger, MD, MPH, Clinical Associate Professor of Medicine and Health Sciences at the University of Washington in Seattle, said that it is important to first address a family’s basic needs before tackling the asthma issue.

In this study, community-based workers assessed the home environment and developed an action plan, which was modified according to the family’s priorities and what they wanted to work on initially. In addition to client education and encouragement, health workers provided feedback and changed goals as necessary.

The researchers worked with landlords and tenants to identify structural repairs and encouraged both groups to make these repairs. They also provided social support and advocacy regarding issues like housing, food, furniture, and jobs, said Dr. Krieger, who is also Chief of Epidemiology, Planning, and Evaluation with the Seattle–King County Department of Public Health. The health workers were not only members of the community—either they or a close family member had asthma.

Two hundred seventy-four families were randomized to either low- or high-intensity interventions. The families in the high-intensity group were given resources such as low-emission vacuum cleaners, microfiltration vacuum bags, allergen-proof bedding covers, doormats, and nontoxic cleaning supplies. The community health workers made five to nine visits to homes throughout one year, averaging seven visits.

In contrast, the families in the low-intensity group received a single home visit, with an action plan and a follow-up phone call. They also received hypoallergenic bedding covers.

Eighty-two percent of the families completed the study’s first year. In both the high- and low-intensity groups there were significant decreases in the number of days with asthma symptoms, with no difference between groups in the degree of symptom reduction. Caregiver quality of life also improved in both groups.

Interestingly, the high-intensity intervention cost about $1,300 per family, but the low-intensity intervention cost only about $220. During a 12-month period, there were comparable savings in both groups because of reduced health service utilization.

WHAT’S RECOMMENDED, WHAT’S POSSIBLE

In a paper describing the Healthy Homes Project,[2] Dr. Krieger and colleagues wrote, “Our work illustrates the gaps between literature-based recommended practices and what is practical in these homes. Many recommended resources (eg, allergy-control bedding encasements or HEPA filters) are not affordable. Some recommended behavioral changes are impractical (eg, pet washing, [doing laundry] in hot water), and others are difficult to sustain given other pressing demands (eg, regular vacuuming).”

One important feature of CBPR is its sustainability, said Dr. Lewis. “We are increasing resources and skills in the community by training outreach workers not only in environmental intervention techniques but also in [integrated pest management]—that’s something that’s going to stay in the community.”

One very important result that both the Healthy Homes Project and Community Action Against Asthma shared was that the families who participated in the studies—and their communities—benefited from the knowledge gained through the research.

—Gale Jurasek