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188 Kearney and Kuranga 23(2), 187191 Commentary
and low-income groups, especially black children, liv- Undoubtedly, the results from our efforts showed
ing in low-income households.6 From 2012 to 2014, marked improvement. However, that is not where the
black children were twice as likely to be hospitalized story should end. While our families (including chil-
for asthma and 4 times as likely to die of asthma as dren) were receptive to asthma education and compli-
white children.7 Costs and quality of life associated ant with medication, we consistently found social fac-
with asthma are responsible for estimated health care tors, related primarily to indoor poor-quality housing,
costs of more than $56 billion each year.8 as a major issue. To elaborate, nearly all of our fam-
Despite advancements in treatment and promising ilies were living in substandard rental housing. Many
breakthroughs in research, there is still no cure for homes we visited suffered from disrepair including
asthma. However, the evidence is clear that when chil- leaky roofs, moldy walls, deteriorating carpet, and
dren with allergic asthma encounter allergens such as plumbing leaks. Frequently, homes needed extensive
dust mites, mold, or chemicals from cleaners or sol- pest control for rodents and cockroaches, far beyond
vents, it can trigger the bodys immune system, which the simple baits and traps that we provided. Repeat-
can further exacerbate an asthma attack. Evidence- edly, we found heating and air-conditioning systems
based research and clinical recommendations clearly that had never been cleaned or serviced and typically
support avoidance of environmental allergen expo- contained biological growth, a dirty filter, and were
sures in the home as key actions for reducing asthma laden with dust. Gaping holes, broken windows, and
attacks.4,9 stained ceiling from leaking roofs were often observed
as catalysts for increased humidity and moisture in-
ECAPP Pilot Project side the home. Typically, tenants were uncomfortable
discussing housing issues with landlords because they
It is now well established in the literature that tar- said they had feared evacuation and no place else to
geted, multicomponent, home-based interventions are live. In some cases, children did not have a bed and
effective for reducing asthma symptoms.10 To test the slept on the floor or children had a bed, but with no
efficacy of reducing asthma among children in our sheets and just a blanket. Our conversations with par-
local community, we initiated a pilot project that ents often included not having enough money to pay
we named the Eastern Carolina Asthma Prevention utility bills or for asthma medicine. In many cases, we
Program (ECAPP). The objective of the study was heard families mention they could not afford to move
to assess the effectiveness of a home-based interven- and that transportation for doctors office visits was
tion by measuring asthma-related symptoms, ED vis- also a challenge. Granted, our persistent and focused
its, unscheduled physicians visits, and quality of life efforts to reduce asthma paid off, without the support
among high-risk, minority children (5-17 years) liv- of a network of services to address housing and social
ing in poor-quality housing conditions. To carry out determinant issues, the probability that the children
this project, we used the King County Asthma pro- in our study will return to the ED is highly probable.
gram model as the framework for our project.11 Over
a 6-month period, we enrolled low-income families
with children with moderate to poorly controlled Strategies for Reducing Asthma Symptoms
asthma (N = 19). Each home visit consisted of an en-
vironmental health professional and an asthma case Based on the published literature and results from
manager, with follow-up to the childs HCPs. As- our pilot study, we strongly recommend efforts that
sessments for each child included an evaluation of go beyond the clinical setting for evaluating asthma
asthma morbiditysymptom frequency, health care symptoms among children in low-income households.
utilization, pulmonary function, and airway inflam- To guide clinical and community action towards im-
mation (fractional exhaled nitric oxide)and an in- proving asthma and environmental housing quality,
door housing evaluation to identify environmental the interplay between key strategies must take into
asthma triggers. As part of the intervention, we account the following (Figure): (1) an evaluation
provided intense asthma education, instructions on of the social determinants of health (eg, housing
proper medication technique, and instructions on us- environment) as part of the HCP patient evaluation;
ing environmental intervention products (eg, mattress (2) enhancement and enforcement of local codes to
and pillow covers, nontoxic cleaning products, proper improve housing conditions; (3) involvement of a
vacuuming) to the child, parent, and/or caregiver. At case manager or community health worker (CHW)
the end of the study, significant reductions were iden- to assist patients with asthma and their families,
tified in the number of childrens ED visits, asthma and, (4) cost reimbursement to those providing de-
symptoms, airway inflammation, and an increased use livery of high-quality, in-home, asthma visits and
of controller medicine.12 services.
Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
March/April 2017 Volume 23, Number 2 www.JPHMP.com 189
Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
190 Kearney and Kuranga 23(2), 187191 Commentary
to provide these services.29 Pathways for equitable (NHIS) data: 2014 lifetime and current asthma. http://www.cdc.gov/
Medicaid reimbursement at the state level for these asthma/nhis/2014/data.htm. Updated March 1, 2016. Accessed
October 12, 2016.
supportive services need to be fully explored and inte- 6. Woods ER, Bhaumik U, Sommer SJ, et al. Community asthma ini-
grated into the fabric of local communities to support tiative to improve health outcomes and reduce disparities among
families that have children with asthma. Medicaid can children with asthma. MMWR Suppl. 2016;65(1):11-20.
7. US Department of Health and Human Services, Office of Minority
play a significant role in building effective commu- Health. Asthma and African Americans. http://minorityhealth.hhs.
nity asthma programs to low-income and medically gov/omh/browse.aspx?lvl=4&lvlid=15. Updated 2016. Accessed
underserved populations.30 Local health departments October 13, 2016.
8. US Department of Health and Human Services, Centers for Dis-
are well positioned to deliver preventive, home-based ease Control and Prevention. Asthma in the US. Vital Signs.
services because they are they are central to the Medi- https://www.cdc.gov/vitalsigns/asthma. Updated 2011. Accessed
caid population and traditionally employ CHWs and October 13, 2016.
9. Horner CC, Bacharier LB. Diagnosis and management of asthma
environmental health professionals. Acting together, in preschool and school-age children: focus on the 2007 NAEPP
they can provide in-home asthma consultations, in- guidelines. Curr Opin Pulm Med. 2009;15(1):52-56.
door environmental assessments while collaborating 10. Postma J, Karr C, Kieckhefer G. Community health workers and
environmental interventions for children with asthma: a systematic
with their local, building, and code enforcement de- review. J Asthma. 2009;46(6):564-576.
partment to address poor, rental housing problems in 11. King County Asthma Program. Healthy Homes Asthma Project
the community. Web site. http://www.kingcounty.gov/depts/health/chronic-
diseases/asthma/health-care-providers/past-programs/healthy-
homes-2.aspx. Updated June 27, 2016. Accessed October 22,
2016.
Conclusions 12. Kearney GD, Johnson LC, Xu X, Balanay JA, Lamm KM, Allen DL.
Eastern Carolina Asthma Prevention Program (ECAPP): an environ-
Until a cure for asthma has been realized, it is imper- mental intervention study among rural and underserved children
ative that communities establish a network support with asthma in eastern North Carolina. Environ Health Insights.
2014;8:27-37.
of clinical, prevention, and intervention strategies to 13. Williams DR, Sternthal M, Wright RJ. Social determinants: tak-
strengthen and provide necessary needed support for ing the social context of asthma seriously. Pediatrics. 2009;123
families with children in low-income households. (suppl 3):S174-S184.
14. Chen E, Schreier HM. Does the social environment contribute to
Provisions under ACA provide new opportunities asthma? Immunol Allergy Clin North Am. 2008;28(3):649-664.
for public health practitioners to move upstream 15. Community Health Workers Section, American Public Health
and to be involved with prevention and intervention Association. https://www.apha.org/apha-communities/member-
sections/community-health-workers. Accessed October 22, 2016.
measures that can move the needle toward reducing 16. Fedder DO, Chang RJ, Curry S, Nichols G. The effectiveness of a
asthma exacerbations, improving indoor housing en- community health worker outreach program on healthcare utiliza-
vironments, and lowering health care costs. As public tion of west Baltimore City Medicaid patients with diabetes, with
or without hypertension. Ethn Dis. 2003;13(1):22-27.
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portunities by assisting clinical providers by extend- comes of Community Health Worker Interventions. Evidence
ing asthma care from the clinic to the community set- Report/Technology Assessment no. 181 (prepared by the RTI
InternationalUniversity of North Carolina Evidence-Based Prac-
ting through home-based visits. The estimated return tice Center under contract no. 290 2007 10056 I.). Rockville, MD:
on investment by achieving these prevention and in- Agency for Healthcare Research and Quality; 2009. AHRQ Publica-
tervention strategies can potentially have tremendous tion No. 09-E014.
18. Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County
medical and health cost benefits for communities and Healthy Homes Project: a randomized, controlled trial of a com-
low-income families that have children with uncon- munity health worker intervention to decrease exposure to indoor
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19. Primomo J, Johnston S, DiBiase F, Nodolf J, Noren L. Evaluation
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Copyright 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.