The challenge of inner-city asthma

Selected Research Issues of Urban Public Health

Health is created within the urban settings of people’s everyday lives. In this paper we define Urban Public Health and compile existing evidence regarding the spatial component of health and disease in urban environments. Although there is already a substantial body of single evidence on the links between urban environments and human health, focus is mostly on individual health behaviors. We look at Urban Public Health through a structural lens that addresses health conditions beyond individual health behaviors and identify not only health risks but also health resources associated with urban structures. Based on existing conceptual frameworks, we structured evidence in the following categories: (i) build and natural environment, (ii) social environment, (iii) governance and urban development. We focused our search to review articles and reviews of reviews for each of the keywords via database PubMed, Cochrane, and Google Scholar in order to cover the range of issues in urban environments. Our results show that linking findings from different disciplines and developing spatial thinking can overcome existing single evidence and make other correlations visible. Further research should use interdisciplinary approaches and focus on health resources and the transformation of urban structures rather than merely on health risks and behavior.

Assessment of predictors for acute asthma attack in asthmatic patients visiting an Ethiopian hospital: are the potential factors still a threat?

BACKGROUND

Recurrent exacerbations in patients with moderate or severe asthma are the major causes of morbidity, mortality and medical expenditure. Identifying predictors of frequent asthma attack might offer the fertile ground of asthma management. However, systematic data on asthma management is scarce in Ethiopia.

OBJECTIVE

The purpose of the present study was to determine predictors of acute asthma attack in patients with asthma attending emergency department of University of Gondar Comprehensive Specialized Hospital (UOGCSH) in Gondar, northwestern Ethiopia.

METHODS

An institutional-based cross-sectional self-administered survey was conducted on 108 asthmatic patients who came to the emergency department of UOGCSH following acute asthma attack. Data were collected through interviewer administered questionnaire. Logistic regression was done to see the possible association of potential factors that may lead to asthma exacerbation.

RESULT

About half of the respondents (51.9%) were female and one third of patients (38.9%) were within the age range of between 46 and 60 years. The leading potential predictor were frequent exposure to various ongoing allergen (68.5%) followed by revelation to occupational sensitizers (67.6%). Chronic sinusitis (AOR = 3.532, 95% CL = 1.116-11.178), obstructive sleep apnea (AOR = 3.425, 95% CL = 1.255-9.356) and psychological disfunctioning (3.689 (1.327-10.255)) were among the significantly associated factors of acute asthma exacerbation.

CONCLUSIONS

Now days, the backbone for long-term asthma management is to prevent exacerbations. Chronic sinusitis, obstructed sleep apnea and psychosocial dysfunction were originated to be considerably linked with repeated exacerbations of asthma. Among those significantly associated predictors, obstructed sleep apnea were the most prevalent one.

The association between asthma-related emergency department visits and pollen and mold spore concentrations in the Bronx, 2001-2008

BACKGROUND

The incidence of asthma morbidity and mortality is highest among minority inner-city populations. Among New York City's five boroughs, the Bronx has the highest rate of asthma-related hospitalizations and mortality. Outdoor air pollutants have been associated with increased asthma-related ED visits (AREDV) in this borough.

OBJECTIVE

To better understand the contribution of pollen and mold to asthma severity in the Bronx.

METHODS

The numbers of daily adult and pediatric AREDV and asthma-related hospitalizations (ARH) from 2001 to 2008 were obtained from two Bronx hospitals. AREDV and ARH data were acquired retrospectively through the Clinical Looking Glass data analysis software. Daily counts for tree, grass and weed pollen and mold spore counts from March 2001 to October 2008 were obtained from the Armonk counting station. All data were statistically analyzed and graphed as daily values.

RESULTS

There were a total of 42 065 AREDV and 10 132 ARH at both Bronx hospitals. There were spring and winter peaks of increased AREDV. Tree pollen counts significantly correlated with total AREDV (rho = 0.3639, p < 0.001), and pediatric (rho = 0.33, p < 0.001) and adult AREDV (rho = 0.28, p < 0.001). ARH positively correlated with tree pollen counts (Spearman rho = 0.2389, p < 0.001).

CONCLUSIONS

There exists a significant association between spring AREDV and ARH and tree pollen concentrations in a highly urbanized area such as the Bronx. Early anticipation of spring pollen peaks based on ongoing surveillance could potentially guide clinical practice and minimize asthma-related ED visits in the Bronx.

Effect of weatherization combined with community health worker in-home education on asthma control

OBJECTIVES

We assessed the benefits of adding weatherization-plus-health interventions to an in-home, community health worker (CHW) education program on asthma control.

METHODS

We used a quasi-experimental design to compare study group homes (n = 34) receiving CHW education and weatherization-plus-health structural interventions with historical comparison group homes (n = 68) receiving only education. Data were collected in King County, Washington, from October 2009 to September 2010.

RESULTS

Over the 1-year study period, the percentage of study group children with not-well-controlled or very poorly controlled asthma decreased more than the comparison group percentage (100% to 28.8% vs 100% to 51.6%; P = .04). Study group caregiver quality-of-life improvements exceeded comparison group improvements (P = .002) by 0.7 units, a clinically important difference. The decrease in study home asthma triggers (evidence of mold, water damage, pests, smoking) was marginally greater than the comparison group decrease (P = .089). Except for mouse allergen, the percentage of study group allergen floor dust samples at or above the detection limit decreased, although most reductions were not statistically significant.

CONCLUSIONS

Combining weatherization and healthy home interventions (e.g., improved ventilation, moisture and mold reduction, carpet replacement, and plumbing repairs) with CHW asthma education significantly improves childhood asthma control.

Asthma exacerbations: origin, effect, and prevention

Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children in the Western world. Despite advances in asthma management, acute exacerbations continue to occur and impose considerable morbidity on patients and constitute a major burden on health care resources. Respiratory tract viruses have emerged as the most frequent triggers for exacerbations in both children and adults; however, the mechanisms underlying these remain poorly understood. More recently, it has become increasingly clear that interactions might exist between viruses and other triggers, increasing the likelihood of an exacerbation. In this article we begin with an overview of the health, economic, and social burden that exacerbations of asthma carry with them. This is followed by a review of the pathogenesis of asthma exacerbations, highlighting the various triggers responsible and multiple interactions that exist between them. The final section first addresses what preventative measures are currently available for asthma exacerbations and subsequently examines which of the new treatments in development might lessen the burden of exacerbations in the future.

Written action plan use in inner-city children: is it independently associated with improved asthma outcomes?

BACKGROUND

Guidelines from the National Asthma Education and Prevention Program stipulate that multicomponent self-management interventions for asthma should include a written action plan (WAP). However the specific, independent effect of WAPs in improving outcomes remains unclear.

OBJECTIVE

To measure the association between WAP use during the previous year and improved asthma outcomes.

METHODS

We conducted a longitudinal quasi-experimental study using data from the Healthy Homes II (HH-II) randomized controlled trial in Seattle, WA. Action plan use during the previous year was measured at exit of HH-II. A participant was a WAP user if he used his action plan every day, almost every day, or once per week, and non-user if he did not meet these criteria. Sensitivity analyses explored less stringent criteria for WAP user designation. Prespecified outcomes were baseline-to-exit changes in asthma control in the previous 2 weeks, Pediatric Asthma Caregiver Quality of Life Scale score, and urgent health services utilization. We used robust linear and logistic regression to compare outcomes across groups.

RESULTS

Two hundred fifty-one patients participated: 112 WAP users; 139 non-users. After adjustment, no significant differences in outcomes were observed between WAP users and non-users. Among a subgroup of participants with recent urgent health services utilization, WAP users had better asthma control than non-users. Changing WAP user criteria to include those who simply owned an action plan, irrespective of use, did not alter our results.

CONCLUSION

WAP use during the previous year was not associated with improved outcomes compared with non-use. Additional studies are needed to assess the long-term, independent benefit of this universally recommended intervention.

Non-antibiotic properties of tetracyclines as anti-allergy and asthma drugs

All available therapies for human allergic disease target IgE mediated pathologic responses after IgE has been produced. We are developing tetracyclines as anti-allergy drugs to prevent IgE production, based on our findings that minocycline or doxycycline treatment of allergic asthmatic humans significantly improves their asthma symptoms, reduces their oral steroid requirements, and strongly suppresses their ongoing IgE responses (ELISA, mast cell mediated cutaneous late phase responses); the tetracyclines also strongly suppress peak IgE responses of BPO-KLH sensitized mice (ELISPOT assay, ELISA, skin tests). The antibiotic activity of the tetracyclines is not required for suppression of IgE responses; inclusion of minocycline or doxycycline in sterile culture prevents anti-CD40/IL-4 mediated induction of memory IgE responses by PBMC of allergic asthmatic patients (ELISA), and induction of specific memory IgE responses by spleen cells of BPO-KLH sensitized mice (ELISPOT assay, ELISA). The tetracyclines affect an epsilon specific pathway because IgM, IgG and IgA responses did not decrease. Further, in humans, DTH responses to recall antigens did not decrease. In related studies, we found that two distinct T cell subsets: CD4+CD60 negative and CD8+CD60+ (CD60 is a ganglioside) (humans) and CD4+ Asialo GM1 ganglioside negative and CD8+Asialo GM1 ganglioside+ (mice), both are required for induction of memory IgE responses. Phosphorylated (phos) p38 MAP kinase, but not phos ERK or phos JNK expression by CD4+ and CD8+, including CD8+CD60+, T cells is increased in allergic asthmatic humans, as is IL-4 and IL-10 production. The tetracyclines appear to target T cell pathways to induce suppression of IgE responses because they suppress phos p38 MAP kinase expression by both CD4+ and CD8+, including CD8+CD60+, T cell subsets, and IL-4 and IL-10, while upregulating IL-2 and IFN gamma, and suppressing IgE responses. Our finding that tetracyclines do not require antibiotic activity to suppress IgE responses opens the door to development of new tetracycline-based and other therapeutics for human allergic disease.

Inadequate health literacy is associated with suboptimal health beliefs in older asthmatics

OBJECTIVES

To examine the relationship between suboptimal asthma beliefs and inadequate health literacy among older adults with asthma.

METHODS

The authors interviewed 100 English- and Spanish-speaking asthmatics (ages >or=50 years) in a New York City primary care clinic (response, 83%). Outcomes included the belief that one does not have asthma when symptoms are absent (no symptoms-no asthma), that asthma is temporary, is curable, and that medications work better if not used all the time. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Belief and health literacy associations were measured with multivariable logistic regression adjusting for age, sex, and race.

RESULTS

The mean age was 61 years; 35% had inadequate health literacy. Those with inadequate literacy were more likely than those with adequate or marginal literacy to have suboptimal beliefs: no symptoms-no asthma, 60% versus 34%, p = .01; temporary, 23% versus 9%, p = .07; curable, 54% versus 25%, p = .004; medication use, 44% versus 21%, p = .03. These relationships remained statistically significant in multivariable analyses that adjusted for age, sex, and race.

CONCLUSIONS

Suboptimal asthma beliefs were more common among older asthmatics with inadequate health literacy. Interventions to improve asthma self-management in older adults should address both belief and health literacy barriers.

Home is Where the Triggers Are: Increasing Asthma Control by Improving the Home Environment

Asthma remains the most common chronic condition of childhood. Strong evidence has linked exposure to allergens and other triggers commonly found in homes to allergen sensitization and asthma incidence and morbidity. A growing body of evidence has demonstrated that a home visit strategy that includes an environmental component that addresses multiple triggers through multiple interventions is effective. Such home visits reduce exposure to triggers, decrease symptoms and urgent health-care use, and increase quality of life. To make home visits widely available will require health-care payor reimbursement, government and health plan funding, training and certification of home visitors, and active referrals from health-care providers. However, a strategy based solely on education and behavior change is limited, because it cannot adequately reduce exposures due to adverse housing conditions. Therefore, approaches that address substandard housing are needed. These include remediation of existing housing and construction of new asthma-friendly homes. Most studies of remediation have made relatively narrow and focused improvements, such as insulation, heating, or ventilation. Outcomes have been mixed. Studies of new asthma-friendly homes are in their infancy, with promising pilot data. Further investigation is needed to establish the effectiveness of improving housing. A final strategy is improving housing quality through policy change, such as implementation of healthy housing guidelines for new construction, enhancement and increased enforcement of housing codes, and assuring smoke-free multi-unit homes. The combination of home visits, improved housing construction, and policy change has great potential for reducing the global burden of asthma.

Assessing the validity of self-reported medication adherence among inner-city asthmatic adults: the Medication Adherence Report Scale for Asthma

BACKGROUND

A validated tool to assess adherence with inhaled corticosteroids (ICS) could help physicians and researchers determine whether poor asthma control is due to poor adherence or severe intrinsic asthma.

OBJECTIVE

To assess the performance of the Medication Adherence Report Scale for Asthma (MARS-A), a 10-item, self-reported measure of adherence with ICS.

METHODS

We interviewed 318 asthmatic adults receiving care at 2 inner-city clinics. Self-reported adherence with ICS was measured by MARS-A at baseline and 1 and 3 months. ICS adherence was measured electronically in 53 patients. Electronic adherence was the percentage of days patients used ICS. Patients with a mean MARS-A score of 4.5 or higher or with electronic adherence of more than 70% were defined as good adherers. We assessed internal validity (Cronbach alpha, test-retest correlations), criterion validity (associations between self-reported adherence and electronic adherence), and construct validity (correlating self-reported adherence with ICS beliefs).

RESULTS

The mean patient age was 47 years; 40% of patients were Hispanic, 40% were black, and 18% were white; 53% had prior asthma hospitalizations; and 70% had prior oral steroid use. Electronic substudy patients were similar to the rest of the cohort in age, sex, race, and asthma severity. MARS-A had good interitem correlation in English and Spanish (Cronbach alpha = 0.85 and 0.86, respectively) and good test-retest reliability (r = 0.65, P < .001). According to electronic measurements, patients used ICS 52% of days. Continuous MARS-A scores correlated with continuous electronic adherence (r = 0.42, P<.001), and dichotomized high self-reported adherence predicted high electronic adherence (odds ratio, 10.6; 95% confidence interval, 2.5-44.5; P < .001). Construct validity was good, with self-reported adherence higher in those saying daily ICS use was important and ICS were controller medications (P = .04).

CONCLUSIONS

MARS-A demonstrated good psychometric performance as a self-reported measure of adherence with ICS among English- and Spanish-speaking, low-income, minority patients with asthma.

Impact of positive and negative beliefs about inhaled corticosteroids on adherence in inner-city asthmatic patients

BACKGROUND

Daily inhaled corticosteroid (ICS) use is the cornerstone of asthma management, although it is often suboptimal, especially in inner-city populations.

OBJECTIVE

To assess the impact of potentially modifiable medication beliefs on adherence with ICS therapy across time.

METHODS

Asthma history, medication beliefs, and ICS therapy adherence were determined in a prospective, observational cohort. Medication beliefs were based on self-regulation and self-efficacy theory. Self-reported adherence with ICS therapy was assessed using the Medication Adherence Reporting Scale, a validated 10-item instrument, at baseline and at 1 and 3 months. Repeated-measures multivariable regression identified beliefs independently associated with adherence across time after adjusting for age, sex, race, and asthma severity.

RESULTS

The 261 patients were low-income minorities with high rates of asthma hospitalization, emergency department visits, intubation, and oral corticosteroid use. Adherence with ICS therapy was stable across time, with 70% of patients saying that they used ICS all or most of the time when asymptomatic. Most patients (82%) thought it was important to use ICS when asymptomatic, although 49% worried about side effects and 37% worried about becoming addicted. Although 82% felt confident in using ICS, 7% felt that their regimen was hard to follow. In multivariable analyses, the odds of adherence increased for those who felt that using ICS when asymptomatic was important (odds ratio [OR], 4.15) and for those who were confident in using ICS (OR, 2.23) and decreased by worries about side effects (OR, 0.52) or feeling the regimen was hard to follow (OR, 0.48).

CONCLUSIONS

Several positive and negative beliefs about ICS were associated with adherence. Eliciting and addressing these potentially modifiable beliefs may help improve adherence and outcomes.

Barriers to adherence to asthma management guidelines among inner-city primary care providers

BACKGROUND

Health care provider adherence to national asthma guidelines is critical in translating evidence-based recommendations into improved outcomes. Unfortunately, provider adherence to the National Heart, Lung, and Blood Institute (NHLBI) guidelines remains low.

OBJECTIVE

To identify barriers to guideline adherence among primary care professionals providing care to inner-city, minority patients with asthma.

METHODS

We surveyed 202 providers from 4 major general medicine practices in East Harlem in New York, New York. The study outcome was self-reported adherence to 5 NHLBI guideline components: inhaled corticosteroid (ICS) use, peak flow (PF) monitoring, action plan use, allergy testing, and influenza vaccination. Potential barriers included lack of agreement with guideline, lack of self-efficacy, lack of outcome expectancy, and external barriers.

RESULTS

Most providers reported adhering to the NHLBI guidelines for ICS use (62%) and for influenza vaccinations (73%). Self-reported adherence was 34% for PF monitoring, 9% for asthma action plan use, and 10% for allergy testing. Multivariate analyses showed that self-efficacy was associated with increased adherence to ICS use (odds ratio [OR], 2.8; P = .03), PF monitoring (OR, 2.3; P = .05), action plan use (OR, 4.9; P = .03), and influenza vaccinations (OR, 3.5; P = .05). Conversely, greater expected patient adherence was associated with increased adherence to PF monitoring (OR, 3.3; P = .03) and influenza vaccination (OR, 3.5; P = .01). Familiarity with specific guideline components and higher level of training were also predictors of adherence.

CONCLUSIONS

Lack of outcome expectancy and poor provider self-efficacy prevent providers from adhering to national asthma guidelines. Efforts to improve provider adherence should address these specific barriers.

Characterizing community-based asthma knowledge in Chicago and its high risk neighborhoods

The goal of this study was to characterize asthma knowledge in high risk neighborhoods compared to a random sample of residents in the Chicago area. The Chicago Community Asthma Survey-32 (CCAS-32) was administered to 1006 Chicago-area residents and 388 residents in 4 high-risk Chicago inner-city neighborhoods. There was a significant difference in asthma knowledge between groups. The general Chicago-area respondents have an average desirable response rate of 71.6% versus 64.7% for respondents in high-risk communities (p < 0.0001). For some aspects of asthma knowledge, e.g., nocturnal cough, cockroach allergen, and vaporizer use, general knowledge was similarly low. For other aspects, such as the need for asymptomatic asthma visits and chest tightness, there were larger gaps between residents of high risk communities and the general community. High-risk neighborhoods in Chicago had lower asthma knowledge compared to the general Chicago community. This discrepancy may be contributing to the disparities seen in asthma morbidity. Public health efforts to increase asthma knowledge in these high risk minority communities may help reduce these disparities. Important misconceptions exist about asthma triggers, signs and symptoms, especially among lower income African American communities, that should be addressed by physicians.

Disparities in smoking cessation among U.S. adults with a history of asthma

BACKGROUND

Socioeconomic status (SES) and racial-ethnic disparities in smoking cessation among U.S. adults with a history of asthma have received limited attention.

PURPOSE

This study examined sociodemographic characteristics associated with smoking cessation in national samples of adults with a self-reported history of asthma.

METHODS

Data from the National Health Interview Survey (years 2000 and 2001 combined) was used to assess the quit ratio (i.e., former smokers as a proportion of ever-smokers) by sociodemographic characteristics, and predictors of former versus current smoking status were examined with multiple logistic regression.

RESULTS

Quit ratios were 53% in Hispanics, 52% in non-Hispanic Whites, and 42% in African American ever-smokers. The quit ratio reached 70% in college graduates versus 45% in those with less than 12 years of education. In multivariate analyses, education and marital status but not racially classified social groups/ethnicity were independently associated with former versus current smoking.

CONCLUSIONS

Expanded smoking cessation efforts are needed among persons with a history of asthma, especially those of lower SES.

Primary care affiliations of adults in a methadone program with onsite care

Methadone maintenance treatment programs (MMTP) often provide onsite primary care. It is unclear whether patients in these settings consider the MMTP their usual source of care. We conducted cross-sectional interviews of 62 adults in an inner-city MMTP with onsite primary care to determine their usual source of care. Program enrollment ranged from 1 to 27 years (median, 4) and 63% attended > or = 5 days per week. Seventy-six percent had > or = 1 chronic disease. Only 53% reported having a usual source of care, which included hospital-based clinics (45%), the MMTP (23%), private physicians (19%), other sites (13%). Patients were more likely to identify the MMTP as their usual source of care if they had cardiovascular disease (RR 6.9, 95% CI 2.2 to 21.9) or HIV (RR 5.6, 95% CI 1.7 to 18.5). Successfully promoting appropriate utilization of onsite primary care may require a better understanding of MMTP patients' perceptions of primary care.

Adverse maternal outcomes in women with asthma: differences by race

PURPOSE

To examine the relationship between race and adverse maternal outcomes in women with asthma.

STUDY DESIGN AND METHODS

This retrospective cohort study examined 11 adverse maternal outcomes across racial groups of 13,900 pregnant women with asthma (age 13 to > or = 40) who gave birth between 1998 and 1999. The data were abstracted from a national database, The National Inpatient Sample (NIS), available through Health Care and Utilization Project (HCUP) maintained and disseminated by the Agency for Healthcare Research and Quality (AHRQ). Maternal age and comorbidities were adjusted in multivariate analysis.

RESULTS

For women with asthma, African Americans were more likely than Whites to have preterm labor and infection of the amniotic cavity; Hispanic women had comparable outcomes with the exception that postdate pregnancy was less likely to be 42 weeks; and Asian/Pacific Islander women had a higher risk of having gestational diabetes and infection of the amniotic cavity.

CLINICAL IMPLICATIONS

As adverse maternal outcomes for women with asthma were higher in minorities, and as minorities have traditionally had more barriers to healthcare, the study results indicate that more effort needs to be made to educate nurses, consumers, and government officials about the potential adverse maternal outcomes of asthma during pregnancy. Public awareness may assist in overcoming the barriers to healthcare experienced by minorities.

Symptom profile and asthma control in school-aged children

BACKGROUND

Children with poorly controlled asthma are at high risk of airway remodeling, sleep disruption, school absenteeism, and limited participation in activities.

OBJECTIVE

To determine asthma prevalence and characterize disease severity and burden in school-aged children.

METHOD

A case-finding study was conducted via a multiple-choice questionnaire and asthma algorithm. Items used for analysis include physician diagnosis of asthma, symptom severity, and health care utilization. The chi2 test was used to determine the significance of differences among cases. Logistic regression was used to evaluate the association of patient factors and asthma indicators.

RESULTS

Of the 5,417 children surveyed, 1,341 (25%) were classified as being at risk of asthma. Of these asthma cases, 55% were positive by diagnosis and algorithm (active), 10% were positive per algorithm alone (suspected), and 35% were positive per diagnosis alone (nonactive). Only 14% of all asthma cases reported experiencing no respiratory symptoms (< 1% active, 2% suspected, and 40% nonactive) compared with 75% of noncases. Also, 75% of noncases reported never missing school compared with 19%, 33%, and 54% of active, suspected, and nonactive asthma cases. African American race, Medicaid enrollment, and male sex were independent predictors of asthma risk. Similarly, African American race, Medicaid enrollment, age, and persistent asthma were independent predictors of emergency department use among asthma cases.

DISCUSSION

Prevalence of active symptoms suggestive of poor asthma control was extremely high among urban, minority children enrolled in Arkansas' largest public school district. Poor asthma control greatly affects quality of life, including school attendance and performance. Interventions should raise expectations and emphasize the importance of achieving asthma control.

No symptoms, no asthma: the acute episodic disease belief is associated with poor self-management among inner-city adults with persistent asthma

OBJECTIVE

Asthma morbidity and mortality is highest among inner-city populations. Suboptimal beliefs about the chronicity of asthma may perpetuate poor asthma control among inner-city asthmatics. This study sought to characterize beliefs about the chronicity of disease and its correlates in a cohort of inner-city adults with persistent asthma.

DESIGN

Prospective, longitudinal, observational cohort study.

PATIENTS

One hundred ninety-eight adults hospitalized with asthma over a 12-month period at an inner-city teaching hospital.

MEASUREMENTS

Sociodemographics, clinical history, disease beliefs, and self-management behaviors were collected by interview. Information on self-reported use of inhaled corticosteroids (ICS), peak flowmeters, and regular asthma visits was collected during hospitalization, and 1 month and 6 months after discharge.

RESULTS

This cohort was predominantly low income and nonwhite, with high rates of prior intubation, oral steroid use, and emergency department visits and hospitalizations. Overall, 53% of patients believed they only had asthma when they were having symptoms, what we call the no symptoms, no asthma belief. Men patients, those > or = 65 years old, and those with no usual place of care had greater odds of having the no symptoms, no asthma belief, and those receiving oral steroids all or most of the time or with symptoms most days had half the odds of having this belief (p < 0.05 for all). The no symptoms, no asthma belief was negatively associated with beliefs about always having asthma, having lung inflammation, or the importance of using ICS, and was positively associated with expecting to be cured. The acute disease belief was associated with one-third lower odds of adherence to ICS when asymptomatic at all three time periods (p < 0.02 for all).

CONCLUSION

The single question, "Do you think you have asthma all of the time, or only when you are having symptoms?" can efficiently identify patients who do not think about or manage their asthma as a chronic disease.

Asthma care and management before an emergency department visit in children in western Michigan: how well does care adhere to guidelines?

OBJECTIVES

Asthma is one of the more common reasons for children's visits to the emergency departments (EDs). Many studies show that the level of asthma care and self-management in children before an ED visit for asthma is often inadequate; however, most of these studies have been conducted in the inner cities of large urban areas. Our objectives were to describe asthma care and management in children treated for asthma in 3 EDs located in an urban, suburban, or rural setting.

METHODS

We studied a prospective patient cohort consisting of children aged 2 to 17 years who presented with an acute asthma exacerbation at 3 EDs in western Michigan. An in-person questionnaire was administered to the parent or guardian during the ED visit. Information was collected on demographics; asthma history; usual asthma care; frequency of symptoms during the last 4 weeks; current asthma treatment, management, and control; and past emergency asthma care. A telephone interview conducted 2 weeks after the ED visit obtained follow-up information. The 8 quality indicators of asthma care and management were defined based on recommendations from national guidelines.

RESULTS

Of 197 children, 70% were enrolled at the urban site, 18% at the suburban site, and 12% at the rural site. The average age was 7.9 years; 60% were male, and 33% were black. At presentation, nearly half (46%) of the children had mild intermittent asthma, 20% had mild persistent asthma, 15% had moderate persistent asthma, and 19% had severe persistent asthma. One quarter of the children had been hospitalized for asthma, and two thirds had at least 1 previous ED visit in the past year. At least 94% had health insurance coverage and 95% reported having a primary care provider. Less than half of the children had attended at least 2 scheduled asthma appointments with their regular asthma care provider in the past year. Although only 5% of the subjects reported that the ED was their only source of asthma care, at least 30% reported that they always went directly to the ED when they needed urgent asthma care. Only 3 in 5 children possessed either a spacer or a peak-flow meter, whereas approximately 2 in 5 reported having a written asthma action plan. Among those with persistent asthma, there was considerable evidence of undertreatment, with 36% not on either an inhaled corticosteroid or a suitable long-term control medication. Only 20% completed a visit with their regular asthma care provider within 1 week of their ED visit.

CONCLUSIONS

Despite very high levels of health care coverage and access to primary care, the overall quality of asthma care and management fell well short of that recommended by national guidelines.

Behavior problems among inner-city children with asthma: findings from a community-based sample

OBJECTIVE

Previous studies have suggested a relationship between childhood asthma and behavior problems. However, few studies have used community-based samples to assess the prevalence of behavior problems among urban children with asthma symptoms. The objective of this study was to evaluate the relationship between asthma symptoms and behavior among a population-based sample of inner-city children and to determine the prevalence of behavioral comorbidity among children with asthma symptoms.

METHODS

In 2003, parents of children who were entering kindergarten in the city of Rochester completed a detailed survey regarding the child's background, medical history (with specific questions about asthma symptoms), and behavior. We compared children with no asthma symptoms, intermittent symptoms, and persistent symptoms with regard to positive peer social skills (eg, makes friends easily), negative peer social skills (eg, fights with other children), task orientation (eg, concentrates well), and shy/anxious behavior (eg, is withdrawn) (validated scales; range: 1-4). We used multivariate regression to determine the independent association between symptom severity and behavioral outcomes.

RESULTS

A total of 1619 children were included (response rate: 80%; mean age: 5.1 year), and 15% had asthma symptoms (8% persistent, 7% intermittent). Average negative peer scores were worse for children with persistent asthma symptoms compared with children with intermittent and no symptoms (mean scores: 1.88, 1.70, and 1.65). Children with persistent symptoms also scored worse than children with no symptoms on the assessment of task orientation (2.85 vs 3.03) and shy/anxious behavior (2.11 vs 1.89). Among children with persistent asthma symptoms, >20% scored >1 SD below average on 2 or more scales, compared with 16% of children with intermittent symptoms and 10% with no symptoms.

CONCLUSIONS

Urban children with persistent asthma symptoms demonstrate more behavior problems across several domains compared with children with no symptoms. These findings suggest a clear need for an early biopsychosocial approach to care for vulnerable children with asthma.

Quality and access to care among a cohort of inner-city adults with asthma: who gets guideline concordant care?

STUDY OBJECTIVES

Asthma morbidity is highest among inner-city populations. This study measured whether quality and access to care over time was concordant with National Asthma Education and Prevention Program (NAEPP) guidelines. It also identified factors associated with NAEPP guideline-concordant care.

DESIGN

A prospective, observational cohort study.

SETTING

An urban academic medical center.

PATIENTS

A consecutive cohort of 198 inner-city adults hospitalized for asthma.

MEASUREMENTS

Detailed information about sociodemographics, asthma history, access to care, history of the current exacerbation, prescription and use of inhaled corticosteroids (ICS) and beta-agonists, and other elements of NAEPP-concordant care (spacers, metered-dose inhaler [MDI] technique, peak flow meters, and action plans) was collected during the index admission and 1 month and 6 months after discharge.

RESULTS

In this predominantly low-income, nonwhite cohort, while 92% of patients had insurance and 80% had a usual source of care, 73% reported delays in seeking care. ICS were prescribed for 77% of patients prior to hospital admission, 83% at 1 month, and 67% at 6 months. Adherence with other NAEPP recommendations were 89% for receipt of MDI instruction, 68% for spacers, 80% for peak flow meters, 31% for written action plans for worsening, and 22% for written plans for attacks. In multivariate analysis, greater asthma severity and having a usual source of care increased the odds of receiving ICS, spacers, and peak flow meters. Care by a specialist increased the odds of receiving action plans. Patients who spoke mostly Spanish were less likely to be given spacers or action plans.

CONCLUSION

Baseline problems with quality and access to care persisted over time. Better systems of care are needed to ensure that high-risk patients receive an appropriate step-up in the quality of ongoing asthma care.

Asthma prevalence and severity in Arab American communities in the Detroit area, Michigan

Immigrant populations provide a unique intersection of cultural and environmental risk factors implicated in asthma etiology. This study focuses on asthma prevalence and severity in 600 Arab American households in metro Detroit, the largest immigrant reception zone for Arab Americans in North America. The survey method introduced a number of novel features: (a) a ranking scheme for the key environmental risk factors for asthma was used to derive an aggregated environmental risk index (ERI) for each household, and (b) an aggregate measure of asthma severity based on symptom frequency and intensity. Environmental risk factors and surrogates for socioeconomic status (SES) were found to be stronger predictors of asthma prevalence than asthma severity, while demographic variables such as English fluency and birth in the United States were better predictors of asthma severity than asthma prevalence. These results suggest that SES variables may be more reflective of environmental exposures in communities involved in this study, while English fluency and birth in the United States may be linked to health care access and utilization behavior that can influence the asthma management. We also found a significant relationship between asthma prevalence and degree of acculturation. Asthma prevalence was highest among moderately acculturated immigrants compared with new immigrants and those who were well acculturated, suggesting that among Arab Americans in the Detroit area, risk factors associated with new immigrant status are replaced by "western" risk factors as the population becomes more acculturated.

Elevated asthma and indoor environmental exposures among Puerto Rican children of East Harlem

OBJECTIVE

East Harlem in New York City, a community with a large Puerto Rican population, has among the highest rates of asthma hospitalizations and mortality in the United States, but it is not known if the high rates are related to the ethnic composition, environmental or community factors, or if the higher rates reflect differentials in access to appropriate asthma care. A survey was conducted to: (a) estimate the prevalence of current asthma by ethnicity among school-age children, (b) assess indoor environmental risk factors for childhood asthma, and (c) assess health care utilization and school absences associated with childhood asthma.

DESIGN

A cross-sectional survey of parents of elementary school children, using a self-administered questionnaire with a 12-month recall on asthma symptoms based on the International Study of Asthma and Allergies in Childhood.

SETTING

Two public elementary schools in East Harlem (n = 1615 students 5-12 years of age).

RESULTS

Among the 1319 respondents (response rate 82%), the prevalence for current asthma (doctor or nurse diagnosis at any time plus wheezing in the past 12 months) was 23%. Puerto Rican children had a prevalence of 35%. Puerto Rican children reported both higher symptomatic frequencies and higher rates of physician diagnosis. Living in a home where cockroaches, rats, or mice had been seen in the past month and with a dust-enhancing heating system also was associated with having asthma, regardless of ethnicity. Compared with other children with asthma, Puerto Rican children with asthma were more likely to live in homes where rats or mice had been seen in the past month. Regardless of ethnicity, children with more frequent, more severe asthma symptoms and incomplete asthma action plans were more likely to have visited the emergency department in the past year. Puerto Rican children were more likely to have missed school because of their asthma in the past year.

CONCLUSION

The prevalence of current asthma was significantly higher among Puerto Ricans, who had higher symptomatic frequency and greater diagnosis rates. Although all children with asthma in the East Harlem study appear to be sensitive to selected indoor environmental risk factors, only Puerto Rican children with asthma appear to be sensitive to the presence of rodents in their buildings. However, their higher school absence rate suggests problems with routine asthma management that could be addressed by improved medical management, programs to help parents manage their children's asthma, or school staff assistance with medications.

The cost-effectiveness of an inner-city asthma intervention for children

BACKGROUND

Comprehensive management efforts to reduce asthma morbidity among children in urban areas with high levels of poverty and large minority populations have been inconclusive. The National Cooperative Inner-City Asthma Study (NCICAS) demonstrated improved symptom outcomes but did not evaluate cost-effectiveness in this population.

OBJECTIVE

We sought to examine the incremental cost-effectiveness of a comprehensive social worker-based education program and environmental control in children with asthma stratified by baseline level of asthma control.

METHODS

We performed a prospective cost-effectiveness analysis alongside a randomized trial. A total of 1033 children and their families residing in 8 inner-city urban areas in the United States were enrolled in the NCICAS. Outcomes included symptom-free days, cost per symptom-free day gained, and annual costs of asthma morbidity compared by baseline symptom control, previous hospitalization, and previous unscheduled physician visits.

RESULTS

The NCICAS intervention significantly reduced asthma symptoms. First-year intervention costs were 245 US dollars higher for the intervention children compared with those receiving usual care. There were no additional intervention-related costs during the second year. When compared with usual care, the intervention improved outcomes at an average additional cost of 9.20 US dollars per symptom-free day gained (95% CI, -12.56 to 55.29 US dollars). The intervention was cost saving in 3 strata of children with increasing asthma severity.

CONCLUSIONS

A multifaceted asthma intervention program reduced symptom days and was cost-effective for inner-city children with asthma. In children with more severe disease, the intervention was substantially more effective and reduced costs compared with that seen in control children. Organizations serving this population should consider this strategy as part of a comprehensive disease-management program for asthma.

Using community-based participatory research to address social determinants of health: lessons learned from Seattle Partners for Healthy Communities

Seattle Partners for Healthy Communities (SPHC) is a multidisciplinary collaboration of community agencies, community activists, public health professionals, academics, and health providers who conduct research aimed at improving the health of urban, socioeconomically marginalized Seattle communities. SPHC uses a community-based participatory research approach to address social factors that affect the health of these communities. This article describes three SPHC projects that focus on social determinants of health, particularly the development of social support and improving housing quality. The characteristics of community participation in each of these projects are discussed and show a spectrum of participation. Although projects successfully addressed proximal social factors affecting health, influencing more distal underlying factors was more difficult. Implications for researchers using a community-based participatory research approach and public health practitioners seeking to engage communities in addressing social determinants of health are presented.