A healthier and safer Indiana

ASTHMA TRIGGERS AND AVOIDANCE BEHAVIORS AMONG INDIANA CHILDREN WITH CURRENT ASTHMA

Amy Brandt, MPH — Chronic Respiratory Disease Epidemiologist

Linda Stemnock — BRFSS Coordinator

CHRONIC RESPIRATORY DISEASE SECTIONMAY 14, 2013

Overview

This slide set was presented at the Indiana Statewide Asthma Conference on May 14, 2013. These slides are intended to be a resource for our partners.

Suggested citation for the presentationIndiana State Department of Health Chronic Respiratory Disease Section and Epidemiology Resource Center Data Analysis Team. (2013). Asthma Triggers and Avoidance Behaviors Among Indiana Children with Current Asthma [PowerPoint slides]. Retrieved from http://www.in.gov/isdh/17279.htm

Citations for individual graphs are on the slides.

Session Learning Objectives

1. Describe Indiana's child population with current asthma.

2. Examine asthma triggers and avoidance behaviors in Indiana children.

3. Translate data findings into areas of need and practice throughout the state.

Background

Home visits are effective, evidence-based interventions that decrease asthma symptoms and exacerbations

A randomized clinical trial in Baltimore found that home visits reduced indoor air pollutants and allergen exposures, which in turn, reduced asthma symptoms1

Intensive home visits that use a multifaceted individualized approach of education, exposure reduction and resources are highly effective in improving health outcomes and changing behaviors2

1. Eggleston, P.A., Butz, A., Rand, C., et al. (2005). Home environmental intervention in inner-city asthma: A randomized controlled clinical trial. Annals of Allergy, Asthma & Immunology; 95:518-524.

2. Krieger, J.W., Takaro, T.K., Song, L., & Weaver, M. (2005). The Seattle-King County Healthy Homes Project: A Randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. American Journal of Public Health, 95, 652-659.

Background: Asthma Triggers

Allergens: Substances that cause no problem for a majority of people but which trigger an allergic reaction in some people. Examples: Mites, cockroaches, mold, animal dander

Irritants: Substances that trigger asthma symptoms by stimulating irritant receptors in the airways. Examples: Cigarette smoke, perfumes, added fragrances, gasoline fumes

Asthma and the Home Environment

Why should we care? Americans spend about 90 percent or more of their time indoors1

Indoor pollutant levels may be two to five times higher than outdoor levels1

People have a greater ability to modify indoor environments The epithelium is more susceptible to damage in children with asthma Exposure to air pollution alters the normal process of lung development2

1. Environmental Protection Agency. (2009). Buildings and their Impact on the Environment: A statistical summary.

2. Gauderman WJ, Avol E, Gilliland F, Vora H, Thomas D, Berhane K, McConnell R, Kuenzli N, Lurmann F, Rappaport E, Margolis H, Bates D,

and Peters J. The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med, 351 (11): 1-11.

Methods

Study Population (N=350) All children (0-17) who were ever diagnosed with asthma and still have

asthma Parents/caregivers gave responses for children

Data Source Indiana Behavioral Risk Factor Surveillance System and Asthma Call

Back Survey Combined data source for years 2006 to 2010

Behavioral Risk Factor Surveillance System

Started by CDC in 1984 Provides state- and national-level prevalence for risk factors,

behaviors and select chronic conditions Random-digit dial telephone survey Largest continuously-conducted health survey in the world Survey conducted for an entire calendar year

Goals and Objectives of BRFSS

Determine prevalence of behaviors associated with leading causes of premature death

Increase public awareness of lifestyle changes that can improve health

Monitor risk factors for trend data, focus on factors that are not improving

Assess progress in meeting national health objectives for health promotion and disease prevention

Assess the impact of state legislation on behavioral risksShare data with state and local agencies

Behavioral Risk Factor Surveillance System

Questionnaire consists of Core questions

• Rotating core questions Optional modules State-added Questions

Cross Tabulations

Adults reporting fair or poor health With current asthma = 37.5%; no current asthma = 16.8%

Adults who are current smokers With current asthma = 32.1%; no current asthma = 24.7%

Adults ever told they had a depressive disorder With current asthma = 38.9%; no current asthma = 18.7%

Number of Completed Surveys per Year Indiana 2002-2013

0

2000

4000

6000

8000

10000

12000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Landline Cell

Random Child Selection and Child Asthma Modules

Use of random child selection and child asthma modules provides child asthma prevalence Random child selection module:

• Month/year of birth• Gender• Race/ethnicity• Relationship to child

Child Asthma Module• Health professional ever said child has asthma• Does child still have asthma?Yes to both of these questions = current child asthma

Indiana included these modules from 2006-2010

Asthma Call Back Survey

Piloted in 2005 with three states – Indiana started in 2006 Funded by the National Asthma Control Program (NACP) in the Air

Pollution and Respiratory Health Branch of the National Center for Environmental Health (NCEH).

If adult or randomly selected child has ever had asthma, they are asked to participate in the ACBS

Contacted within two weeks Separate survey from BRFSS, but links to responses in BRFSS Parent/guardian most familiar with selected child is proxy For this presentation, using data from the Child ACBS

Asthma Call Back Survey contents

Questions cover: Age and time since diagnosis Time since they talked to a doctor, took asthma medication Frequency/duration of symptoms Frequency of asthma episodes/attacks Insurance Activity limitations MD/urgent/ER/hospital visits for asthma Action plan/course to manage asthma Triggers in home Detailed information on prescription medication

Prevalence of current asthma among children, Indiana and the United States, 2005–2010, 2011*

*The 2011 prevalence estimate was determined using a new, more precise methodology, including the addition of cell phone respondents and new weighting techniques; therefore, the 2011 estimate should not be compared to earlier prevalence estimates.

Source: CDC and ISDH DAT. (2012). Behavioral Risk Factor Surveillance System Prevalence Data, 2005-2011.

9.5

0

2

4

6

8

10

12

2005 2006 2007 2008 2009 2010 2011

Pe

rce

nt

Year

Indiana United States

Child Current Asthma Prevalence for Sex and Race, Indiana, 2011

Source: CDC and ISDH DAT. (2012). Behavioral Risk Factor Surveillance System Prevalence Data, 2011.

9.56.1

11.27.4

22.7

9.7

0

5

10

15

20

25

30

35

Overall Male Female White Black Hispanic

Pe

rce

nt

Results

Impact of asthma on Indiana’s children*, 2006–2010

*Children with current asthmaSource: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor

Surveillance System Asthma Call-back Survey, 2006-2010.

61.2

41.4

45.7

0 20 40 60 80

had activity limitations due to asthma?

had a flu shot?

seen a health professional for urgent treatment of worsening

asthma symptoms or for an asthma attack?

Percent

In the past 12 months, has the child with current asthma . . .

Medical management of asthma, children with current asthma, Indiana, 2006–2010

Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor Surveillance System Asthma Call-back Survey, 2006-2010.

81.7

53.1

44.3

0 20 40 60 80 100

Never taken a course to manage asthma

Never given an asthma action plan

Health professional advised changes in home/school to improve child's asthma

Percent

Definition: Triggers• Cigarettes smoked in home• Saw/smelled mold• Saw cockroaches• Saw rodents• Inside pets• Pets allowed in child’s bedroom

High-Level Triggers

• Kitchen/bath fans not used• Carpeting in child’s bedroom• No mattress cover• No pillow cover• Hot water not used for cleaning sheets• Unvented gas logs/fireplace• Air cleaner not used• Dehumidifier not used• Wood burning stove/fireplace• Gas used for cooking

Low-Level Triggers

Distribution of asthma triggers present in child’s* home, 2006–2010

*Children who currently have asthma.Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor

Surveillance System Asthma Call-back Survey, 2006-2010.

0.01.0 1.4

4.6

7.0

12.6

16.216.8

13.0 13.414.0

0

2

4

6

8

10

12

14

16

18

None One Two Three Four Five Six Seven Eight Nine Ten or More

Pe

rce

nt

Household Management of Asthma: Prevalence of environmental triggers and avoidance behaviors

Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor Surveillance System Asthma Call-back Survey, 2006-2010.

Low-level triggers/behaviors Percent

Carpeting or rugs in child's bedroom 81.4

Dehumidifier not used 71.9

Pillow cover not used 68.2

Aircleaner not used 62.2

Mattress cover not used 61.5

Hot water not used for child's sheets/pillowcases 61.2

Gas used for cooking 41.8

Kitchen exhaust fan not used 40.8

Exhaust fan not used in child's bathroom 34.8

Wood-burning fireplace or wood stove used 16.5

Unvented gas logs/fireplace used in child's home 7.6

Distribution of the number of low-level triggers present in the home

Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor Surveillance System Asthma Call-back Survey, 2006-2010.

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10

Nu

mb

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of

Ho

us

eh

old

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Number of triggers

Household Management of Asthma: Prevalence of environmental triggers and avoidance behaviors

Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor Surveillance System Asthma Call-back Survey, 2006-2010.

High-level triggers/behaviors Percent

Inside pets 59.8

Pets allowed in child's bedroom 58.2

Saw mice or rats 10.5

Cigarettes smoked inside the home 9.0

Seen or smelled mold 5.6

Saw cockroaches 2.6

Distribution of the number of high-level triggers present in the home

Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor Surveillance System Asthma Call-back Survey, 2006-2010.

0

20

40

60

80

100

120

140

0 1 2 3 4

Nu

mb

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of

Ho

us

eh

old

s

Number of triggers in home

Had asthma attack/episode in past year by number and type of triggers in the child’s* home

*Children who currently have asthma.Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor

Surveillance System Asthma Call-back Survey, 2006-2010.

0.0%6.6%

29.0%

64.4%

28.4%

62.4%

9.1%

0.0%0%

20%

40%

60%

80%

100%

None 1-2 triggers 3-4 triggers 5+ triggers

Pe

rce

nt

Low Level High Level

Ever taken a course to manage asthma by number and type of triggers in the child’s* home

*Children who currently have asthma.Source: Centers for Disease Control and Prevention and ISDH Data Analysis Team. (2013). Behavioral Risk Factor

Surveillance System Asthma Call-back Survey, 2006-2010.

0.0%

17.8%

39.1%43.1%

31.5%

57.6%

10.8%

0.0%0%

10%

20%

30%

40%

50%

60%

70%

None 1-2 triggers 3-4 triggers 5-10 triggers

Pe

rce

nt

Low Level High Level

Association between triggers and health outcomes

Having at least one high level trigger present in the child’s home increases the odds of an asthma attack/episode by 14% compared to children who do not have a high level trigger.

A lower percentage of children with 4+ low level triggers (58.5%) in their household were told by a health professional to modify their environment compared to children with 3 or less triggers.

Why Do Home Visits?

“We should not expect to change lives dramatically, particularly by visiting people sometimes once or twice a month. But we

should expect to make a dent, to make their lives and the lives of their children at least a

little better, taking small steps towards change.”

--Matthew Melmed

How Do Home Visits Help?

Secondary prevention Educate family on the pertinent health condition Observe possible causes of health condition in the home

Identify other health needs within the familyIncrease family’s self-efficacy

The belief in one’s ability to exercise influence over one’s own life

Engaging Families

Ask open-ended questionsUse a conversational approach, rather than

interviewingEffective Verbal Messages

Keep important messages succinct and free of jargon Be mindful of the possibility for resistance in the listener

Effective Nonverbal Messages Facial expressions Posture and gestures

Effective Listening Requires the listener to put aside their thoughts and agenda Conveying an attitude of respect and acceptance

A desire to understand the speaker

Examples of triggers to look for in the home

Secondhand smoke Home or car where smoking is allowed Can be found in clothing

Dust Mites Mattresses, bedding, carpets, etc.

Pests (cockroaches, rodents) Areas with food and standing water Cluttered areas with paper and cardboard

Mold Areas with excess moisture

Nitrogen Dioxide Gas cooking appliances, fireplaces, woodstoves

Pets Does the pet sleep with the patient?

http://epa.gov/asthma/pdfs/home_environment_checklist.pdf

Resources

211: information hotline (English and Spanish speakers) Local health department sanitarian Examples of agencies in Indiana currently doing home visits

Marion County Public Health Department Parkview Hospital in Fort Wayne St. Mary’s Health System in Evansville

Source: www.healthyhomespartnership.net

Questions?

Contact InformationLinda StemnockBRFSS Coordinator

Indiana State Department of Healthlstemnoc@isdh.in.gov

(317) 233-7536

Amy BrandtChronic Respiratory Disease Epidemiologist

Indiana State Department of Healthabrandt@isdh.in.gov

(317) 233-7793