Effectiveness of Community Based Interventions for Children with Asthma

Noreen M. Clark, PhDMyron E. Wegman Distinguished University ProfessorDirector, Center for Managing Chronic DiseaseUniversity of Michigan

Effectiveness of Community Based Interventions for Children with Asthma

Noreen M. Clark, PhDMyron E. Wegman Distinguished University ProfessorDirector, Center for Managing Chronic DiseaseUniversity of Michigan

In asthma, four types of community interventions have been examined

Outreach from health care institutions

Home based computer programs School based programs Coalitions and partnerships

Outreach to patients’ homes by community health workers to:

Provide self-management education

Assist with environmental modifications

Summary of Studies: Community health worker based randomized trials

PublicationSample Size Intervention Outcome

Williams et al, National Medical Association, February 2006

N=410Modification of Environment

Reduction in dust mite; improved functioning (most severe)

Krieger et al, American Journal of Public Health, April 2005

N=274

High vs. low intensity environmental control & education

Improved quality of life; less urgent care

Evans et al, Journal of Pediatrics, September 1999

N=1033

Social workers individualized education for family

Fewer sick days; less hospitalization; greatest effect for severe asthma

Carter et al, Journal of Allergy & Clinical Immunology, 2001

N=104Assistance with home prevention (3 Groups)

Reduced acute visits in active intervention; slight reduction in allergen presence; decrease in mite allergen

Brown et al, Journal of Pediatric Psychology, 2002

N=95"Wee Wheezers" at home < 7 years old

Fewer SX days for younger children only. Better quality of life for parents of younger children

Issues

Effects of environment change not separated from education

Cost of environmental modifications

Computer Programs for Home Use

Computer programs focus on games and problem solving

Summary of Studies: Computer programs at home randomized trials

Publication Sample Size Intervention Outcome

Hass et al, Journal of Pediatric Health Care, March 2003

N=101 Asthma Game NS

Shegog et al, Journal American Inform Association, January 2001

N=76Self Management

EducationIncreased self-

efficacy

Homer et al, Pediatrics, July 2000

N=137Asthma &

Management CAI vs. Written

NS

Issues

Limited success Majority of studies test knowledge Small numbers Overlooks children without computers

School Based Interventions

Focus on child’s self-management

Conducted with and without school based health services

Summary of Studies: School based randomized trials

Publication Sample Size Intervention Outcomes

Evans et al, Health Education Quarterly, Fall 1997

N=239 Self ManagementReduced SX; reduced ED

visits; better grades

Shah et al, BMJ, March 2001

N=272Peer Education re:

Asthma Management

Improved quality of life and reduced absenteeism

Gus et al, Journal of Adolescent Health, October 2005

N=273School Based Asthma

Clinic

Reduced hospital & ED visits; care costs reduced

Tinkelman & Schwartz, Journal of Asthma, June 2004

N=41Asthma Self-

Management Education

Reduced missed school days & unscheduled doctor visits; reduced SX

Halferman et al, Archives of Pediatric & Adolescent Medicine, May 2004

N=180 School Based MedsReduced missed school

days and SX

Clark et al, Chest, May 2004

N=835Comprehensive

Management Education

Reduced SX in persistent group; better grades; fewer missed school days

Issues

Difficult in school systems with limited resources

Replication generally does not occur Sponsorship not forthcoming

Coalitions and Partnerships

200+ asthma coalitions in the United States

Focus on community-wide changes

Bring disparate but key groups together

Evaluation Logic

Eventual improved health status results from: Health system-wide changes Community-wide policies

Summary of Studies: Community Coalitions & Partnerships

Publication Intervention Outcomes

Kreger et al, Report of California Community Action to Fight Asthma Initiative, 2005

11 Coalitions Across California

• Community education re: housing rights• Public education re: asthma• School environment assessments• Advocacy for air quality• Asthma action plans in schools community-wide

Fisher et al, Pediatrics, December 2006

Neighborhood Asthma Coalition

Reduced acute care rates among high level of participants

Clark et al, Health Promotion Practice, April 2006

7 Asthma Coalitions Across the United States

• Community wide pt registries (2)• Care coordinators across hospitals & clinics (2)• Integration of CHW with Clinic Care (4)• Community wide education for clinicians (6)• Environment Control Policies (1)

Issues

Lack of outcome of studies Support has been from foundations Population data not collected

In Summary

Good models of interventions exist for: community outreach (CHW) school based programs coalitions and partnerships

Trends

Less examination of social, behavioral, policy interventions

Work of community health workers not being reimbursed

No continuing sponsorship for school programs or coalitions

Proven programs not disseminated Reinvention of the wheel

Asthma fallen off the radar

Ideas to Enhance Application Initiate a targeted campaign to reach

health system influentials: ongoing messages and encouragement to support use of proven programs

Provide a compendium of proven programs and “how to’s” as part of the campaign

Funders initiate research into effective channels for dissemination of programs

Reinvigorate support for community intervention research including evaluation methodology

Effectiveness of Community Based Interventions for Children with Asthma

Noreen M. Clark, PhDMyron E. Wegman Distinguished University ProfessorDirector, Center for Managing Chronic DiseaseUniversity of Michigan