A Review of Community-Based Asthma Interventions for Inner-City Children

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<ul><li><p>PEDIATRIC ASTHMA, ALLERGY &amp; IMMUNOLOGYVolume 8, Number 3, 1994Mary Ann Liebert, Inc., Publishers</p><p>A Review of Community-Based Asthma Interventions forInner-City Children</p><p>ARLENE M. BUTZ, B.S.N., ScD.,1 FLOYD J. MALVEAUX, M.D., Ph.D.,2PEYTON A. EGGLESTON, M.D.,3 LERA THOMPSON, M.P.H.,2KAREN HUSS, B.S.N., D.N.Sc.,1 and CYNTHIA S. RAND, Ph.D.4</p><p>ABSTRACT</p><p>Despite significant progress in asthma treatment, morbidity and mortality rates for childrenwith asthma have increased over the past decade. Poverty has been associated with an increased prevalence of asthma, level of severity, and increased hospitalizations due to asthma.Educational asthma self-management programs have been shown to reduce school absenteeism and symptoms, change health care utilization, and improve self management skills.However, most studies have included hospital-based or nondisadvantaged children. This paper reviews five unique community-based asthma management programs targeting inner-citydisadvantaged children. The asthma intervention studies were selected for review based on:(1) community involvement in subject recruitment or administration of the intervention; (2)basic asthma self-management education included as part of intervention; and (3) focusing oninner-city disadvantaged children and families.</p><p>Similar findings across the five community-based programs included the need for educatinghealth professionals regarding asthma management, increased attention to the home environment, and targeting asthma education programs to undertreated groups who lack adequateaccess to care. Use of community settings, such as public schools, churches or community-based clinics, are optimal sites for delivering community-based asthma management programs. Linkages and partnerships between health professionals and community/local government organizations or parent groups can facilitate solving the housing, social, and medicalaccess problems of many inner-city families detected by the studies.</p><p>INTRODUCTION</p><p>Despite significant progress in asthma treatment, there has been an increase in morbidity and mortalityrates for children with asthma over the past decade.*1"*' It is estimated that there are more than 4500 deathsper year in the United States from asthma.(5) Prevalence rates for childhood asthma are persistently higher in</p><p>'The Johns Hopkins University School of Nursing and 3School of Medicine, Department of Pediatrie Allergy andImmunology, "School of Medicine, Division of Pulmonary and Critical Care Medicine, all in Baltimore, Maryland, and2Howard University, Department of Microbiology, Washington, D.C.</p><p>149</p></li><li><p>BUTZ ET AL.</p><p>African-American and impoverished children.'14' Poverty has been associated with an increased prevalence ofasthma,'4' level of severity,' 16-7' and hospitalizations due to asthma.'8' Not only are children in low-incomefamilies more likely to experience many illnesses, particularly chronic illnesses,'9' but they are also less likelyto receive adequate medical care.'10' Additional explanations for the increase in asthma morbidity and mortality in African-American children include increased exposure to environmental allergens and irritants (e.g.,passive cigarette smoke, cockroaches), lack of regular asthma care, inconsistent or nonexistent education regarding appropriate asthma medication use, and inadequate social resources.'11-13'</p><p>Several educational self-management programs have demonstrated benefits in either reduced school absenteeism and symptoms reports, change in health service utilization, and improved self-management skills.'14-16'However, the majority of these intervention programs have included biased samples (e.g., volunteer or clinic-based subjects with few inner-city populations) and were clinic- or hospital-based rather than implemented directly in the community."7' Major elements shared by effective community-based asthma management programs include optimal clinical care through individualized medication plans, emphasis on parent and patienteducation, and attempts to reduce barriers to patient adherence.'18' The purpose of this paper is to review fiveunique community-based asthma management programs and propose recommendations for future programdevelopment and implementation.</p><p>REVffiW OF FrVE COMMUNITY-BASED ASTHMA INTERVENTIONS</p><p>Five community-based asthma intervention studies were selected for review based on the following criteria:first, subject recruitment and/or administration of the intervention was conducted exclusively in the community and community sites included public schools, community health clinics, or in the childrens' homes; second, all studies included basic asthma self-management education for parents and children; third, all studies focused on inner-city disadvantaged children and families.</p><p>Case management and quality assurance programCase management and quality assurance techniques were utilized as an intervention for improving asthma</p><p>care of Medicaid-eligible, inner-city children in Baltimore, Maryland.'18' Eighty-eight preschool children, whohad two or more emergency room visits for asthma within a three-month period, were targeted to receive theintervention. This program had three major components: assessment of the care of individual patients withfeedback to their primary care providers (PCPs), periodic contact with the parents by a nurse, and provision ofasthma education materials to parents.</p><p>Specifically, telephone interviews with parents were conducted by the nurse to assess knowledge of homeasthma care and the type of care prescribed by the child's physician. Twenty-four hour telephone consultationfor asthma by the nurse or physician backup was available to the families. Each child's asthma managementplan was reviewed by a physician with the nurse to identify aspects of the patient's medical care that could beimproved. These included drug regimens, specific parent educational goals, and the need for allergy consultation. The patient's PCP was then contacted by the nurse and offered medical care suggestions for treatment ofthe child's asthma. No physician refused permission for a patient to participate. Bimonthly telephone callswere made to the parents in order to assess medication and educational needs. After any acute care visit to theemergency room, a telephone call was made to the parents, inquiring about the child's status and parents' understanding of the treatment plan. Written asthma education materials were also sent to the parents on a routinebasis.</p><p>Outcome measures were evaluated and compared during two periods, including a three-month preinterven-tion and a three-month postintervention time period. From the first to the second period, acute care visits decreased by 50% suggesting that the intervention had some effect on acute care utilization. The authors conclude that use of case management and quality assurance techniques improved asthma management skills forall involved with the care of a child with asthma (e.g., the child, parent, physician, pharmacist, and teacher) asutilized in this program.</p><p>150</p></li><li><p>COMMUNITY-BASED ASTHMA INTERVENTIONS</p><p>Community-based educational asthma programThis self-management educational intervention, implemented in public schools in Villawood, Sydney,</p><p>Australia, was targeted to children with asthma and their parents, doctors, pharmacists, school teachers, andcommunity nurses.'17' Initially, 132 children were recruited from economically disadvantaged communities(intervention group, 72; control group, 60) who had: (1) a doctor's diagnosis of asthma; (2) a current asthmamedicine requirement; and (3) current bronchial hyperresponsiveness and recent symptoms. Each child assigned to the intervention group received two educational sessions at school with their parents present during aone-month period. An overview of a management plan was given to each family and their physician. Each family was asked to consult with their doctor to discuss the plan. All physicians who cared for children in the intervention group and all local pharmacists were invited to attend workshops that presented a well-used and respected asthma management plan.'19' All community health nurses from local health centers and all schoolteachers from the community received an asthma educational program conducted in their workplaces. If anyfamily member, doctor, or pharmacist did not attend the educational sessions, they were subsequently mailedasthma educational materials.</p><p>Attendance rates for the educational sessions varied by group. All teacher and community health nurses attended the sessions as compared to very few pharmacists (21 %) and doctors (20%). Improvement in lung function in the children receiving the intervention was detected at the six month follow-up. In the interventiongroup, FEVj (forced expiratory volume in 1 second) was significantly improved from baseline (mean = 1.78L) as compared to the six-month follow-up (mean = 2.13 L; &lt; 0.001). Unscheduled doctor or emergencyroom visits were also significantly reduced between the six-month follow-up and baseline (baseline mean =2.68, six month mean = 1.5\;p&lt; 0.01).</p><p>"Open Airways" school programProviding a school-based asthma education program that focused primarily on teaching the child and pro</p><p>viding parental participation was the goal of this study in New York City.'20' Twelve public elementary schoolsfrom two New York community school districts agreed to enroll children with asthma, based on parental reports of at least three episodes of asthma in the past year. Each school was paired according to ethnic composition and size and then randomly selected to receive the education program or serve as a control school. A totalof 239 low-income children (experimental, 134; control group, 105) participated in the one-year follow-upstudy. Parents did not attend the educational sessions but received written materials regarding managementskills the children were learning. The asthma educational program, entitled "Open Airways"'21' was adaptedfor school use and emphasized the child's responsibility for recognizing symptoms and taking appropriatemanagement steps. The "Open Airways" school program, held during the second day, consisted of six 60-minute sessions for groups ofeight to 12 children focusing on children's independent actions as self-managers.</p><p>One-year follow-up data showed that the group receiving the educational program (experimental group) hadhigher scores on an index of asthma management (p &lt; 0.05), greater self-efficacy of asthma management skills(p = 0.05), more influence on parents' asthma management decisions (p &lt; 0.05), better grades in school, fewerepisodes of asthma (p &lt; 0.01), and episodes of shorter average duration (p &lt; 0.01) compared to the controlgroup. No differences were observed for changes in the number of school absences.'20'</p><p>Community-based asthma education intervention with community outreachThis randomized clinical trial compared a school-based educational and a community health worker (CHW)</p><p>outreach intervention to determine if separate or combined interventions were effective in reducing asthmamorbidity in inner-city children from Baltimore, Maryland and Washington, DC.'22' Children with asthma(N = 392) were identified in 42 inner-city elementary schools. Each school was randomized into one of fourgroups: (1) minimal intervention; (2) school-based asthma education program; (3) a community health worker(CHW) program; and (4) a combined school-based education/community health worker program. The minimal intervention group received educational literature sent home with the children. The school-based education program consisted of six educational sessions (A+ Asthma curriculum) designed to increase the asthmaticchild's knowledge and management skills. The A+ Asthma curriculum is culturally sensitive, since it was pi-</p><p>151</p></li><li><p>BUTZ ET AL.</p><p>loted with inner-city children for appropriate language and illustrations. The educational sessions are deliveredto the children in the school setting and cover triggers, medication use, an asthma action plan for acute asthmaepisodes, decision making about asthma care, and environmental control techniques. The CHW interventionconsisted of home visits to assigned families by trained lay personnel, recruited from the community and supervised by a nurse, to assist families in overcoming barriers to asthma care. Community health workers offered referral information and emotional support as well as basic asthma information. Medical issues were notaddressed by the CHWs. Rather, medical issues were referred to the nurse supervisor and the child's primarycare provider. Primary care physicians, identified by each parent, were mailed a copy of the National AsthmaEducation Program (NAEP) recommendations'23' along with a brief description of the study and its goals.</p><p>Lack of regular primary care for asthma management and significant misuse and misunderstandings ofasthma medications were identified in this sample of inner-city children with asthma. Medication use was often in conflict with the recommendations set forth in the NAEP guidelines. More than 80% of the children reported using 2 agonist medication, and of these, nearly 32% reported using no other medication. Only 1 in 5reported use of inhaled anti-inflammatory medications. Use of home remedies, including herbal teas andcough medicine, were reported by 26% of the parents. Fewer than 10% of these children reported using a peakflow meter on a regular basis.</p><p>Several environmental problems were identified by the CHWs during the home assessments.'24' One-quarter of the families reported a roach problem and 19% reported rodents present in their household. Over half(56%) of the families reported one or more smokers living in the homes of the children. Use of plastic zipperedcovers for mattresses (13%) and pillows (3%) was low and over one-fourth (26.1%) of families reported having a pet (cat, dog, or bird).</p><p>Preliminary analysis of the 12-month follow-up data revealed that the combined intervention program(school-based and outreach by CHWs) reduced high rates of ER (emergency room) use, activity restrictions,and parental days lost from work. Additionally, this group reported having a PCP. However, also evident at the12-month follow-up, were continued high rates of ER use for asthma care and use of suboptimal asthma therapies, consistent with previous interventions"8' examining physician practices.</p><p>Community/school-based asthma educational program: A community partnershipThis ongoing demonstration project recruits children, identified with asthma, from four schools in one cir</p><p>cumscribed, inner-city community in Baltimore, Maryland (P. Eggleston, personal communication, 1994).The goals of the project are to reduce school absenteeism, asthma symptoms, and ER visits. A partnership wasdeveloped between community leaders and health professionals from a large academic medical institution.Incorporated into the project, is a specially trained nurse who is assigned to the f...</p></li></ul>


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