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Niebur H, Rookwood A, Karki B, Abresch C. Toward a new model of childhood asthma care: community needs assessment in an underserved urban population. J Asthma 2023; 60:2064-2073. [PMID: 37171134 DOI: 10.1080/02770903.2023.2213351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/25/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVES The objective of this study was to utilize a community-engaged research approach to better understand gaps and opportunities for improving asthma care from the perspectives of patients, caregivers, community organization representatives, and healthcare providers in a predominantly minority community. METHODS Forty-one participants from four groups (patients, caregivers, community organization representatives, healthcare providers) participated in interviews or focus groups. A phenomenological approach to this qualitative research allowed the research team to better understand the lived experiences of families seeking asthma care in this community. RESULTS Five gaps and five corresponding opportunities were identified. The gaps identified were unequal healthcare resource distribution; underrepresentation of health professionals from diverse backgrounds; experiences of environmental racism; mistrust, bias, and discrimination in healthcare encounters; and systemic marginalization of communities. The opportunities identified include increasing healthcare infrastructure and accessibility; increasing racially, culturally, and linguistically congruent healthcare; implementing equitable improvements to the built environment; building relationships with communities and individuals; and acknowledging communities' strengths and resilience. CONCLUSION This study identified systemic gaps to asthma care that are of prominent concern to the community.
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Affiliation(s)
- Hana Niebur
- Department of Pediatrics, University of NE Medical Center, Omaha, USA
| | - Aislinn Rookwood
- Department of Pediatrics, University of NE Medical Center, Omaha, USA
- Department of Health Promotion, University of Nebraska Medical Center, Omaha, USA
| | - Bibhusha Karki
- Division of Nursing, Midwifery and Social work, University of Manchester, Manchester, UK
| | - Chad Abresch
- Department of Pediatrics, University of NE Medical Center, Omaha, USA
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Lemire E, Samuels EA, Wang W, Haber A. Unequal Housing Conditions And Code Enforcement Contribute To Asthma Disparities In Boston, Massachusetts. Health Aff (Millwood) 2022; 41:563-572. [PMID: 35377754 DOI: 10.1377/hlthaff.2021.01403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Housing quality is a primary determinant of asthma disparities by race and social class in the US. We sought to assess how housing code enforcement systems in Boston, Massachusetts, address tenants' reports of asthma triggers. After adjustment for income and other neighborhood characteristics, racial demographics were significantly associated with asthma trigger incidence. For each 10 percent decrease in neighborhood proportion of White residents, trigger incidence increased by 3.14 reports per thousand residents. These disparities persisted during the study period (from 2011 through 2021), and for mold, which is an established asthma trigger, regressions showed that racial disparities are widening. The municipal response also demonstrated disparities: In neighborhoods with the fewest White residents compared to neighborhoods with the most White residents, adjusted models showed a 17 percent (3.51 days) slower median time until cases (tenant requests for inspections to the Inspectional Services Department) were closed, a 14 percent higher probability of being flagged as overdue, and a 54.4 percent lower probability of a repair. We found evidence that in Boston, despite several healthy housing initiatives, current regulatory systems are insufficient to address disparities in access to healthy housing. To reduce disparities in asthma burden, stronger inspectional standards and further enforcement policies to increase landlords' accountability and support tenants' rights to have repairs made are essential.
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Affiliation(s)
- Evan Lemire
- Evan Lemire, Harvard University, Boston, Massachusetts
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3
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Trivedi M, Hoque S, Shillan H, Seay H, Spano M, Gaffin J, Phipatanakul W, Rosal MC, Garg A, Gerald LB, Broder-Fingert S, Byatt N, Lemon S, Pbert L. CENTER-IT: a novel methodology for adapting multi-level interventions using the Consolidated Framework for Implementation Research-a case example of a school-supervised asthma intervention. Implement Sci Commun 2022; 3:33. [PMID: 35346393 PMCID: PMC8962032 DOI: 10.1186/s43058-022-00283-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Implementation science frameworks advise the engagement of multi-level partners (at the patient, provider, and systems level) to adapt and increase the uptake of evidence-based practices (EBPs). However, there is little guidance to ensure that systems-level adaptations reflect the voices of providers who deliver and patients/caregivers who receive EBPs. Methods We present a novel methodology, grounded in the Consolidated Framework for Implementation Research (CFIR), which anchors the engagement of multi-level partners to the voices of individuals who deliver and receive EBPs. Using the CFIR domains: intervention adaptation, individuals involved, inner/outer setting, and process, we illustrate our 4-step methodology through a case example of Asthma Link, a school-supervised asthma management intervention. In step 1, we interviewed “individuals involved” in the intervention (providers/caregivers/patients of Asthma Link) to identify implementation barriers. In step 2, we selected systems-level partners in the “inner and outer setting” that could assist with addressing these barriers. In step 3, we presented the barriers to these systems-level partners and conducted semi-structured interviews to elicit their recommended solutions (process). Interviews were audio-recorded, transcribed, and open-coded. A theoretical sampling model and deductive reasoning were used to identify solutions to implementation barriers. In step 4, we utilized multi-level input to adapt the Asthma Link intervention. Results Identified barriers included inability to obtain two inhalers for home and school use, inconsistent delivery of the inhaler to school by families, and challenges when schools did not have a nurse. Interviews conducted with school/clinic leaders, pharmacists, payors, legislators, and policymakers (n=22) elicited solutions to address provider and patient/caregiver-identified barriers, including (1) establishing a Medicaid-specific pharmacy policy to allow dispensation of two inhalers, (2) utilizing pharmacy-school delivery services to ensure medication reaches schools, and (3) identifying alternate (non-nurse) officials to supervise medication administration. The iterative process of engaging multi-level partners helped to create an adapted Asthma Link intervention, primed for effective implementation. Conclusions This novel methodology, grounded in the CFIR, ensures that systems-level changes that require the engagement of multi-level partners reflect the voices of individuals who deliver and receive EBPs. This methodology demonstrates the dynamic interplay of CFIR domains to advance the field of implementation science.
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Affiliation(s)
- Michelle Trivedi
- Division of Pulmonary Medicine, Department of Pediatrics, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA. .,Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA.
| | - Shushmita Hoque
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Holly Shillan
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Hannah Seay
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Michelle Spano
- Division of Pulmonary Medicine, Department of Pediatrics, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA
| | - Jonathan Gaffin
- Division of Pulmonary Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wanda Phipatanakul
- Division of Asthma, Allergy, and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Milagros C Rosal
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA
| | - Arvin Garg
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Lynn B Gerald
- Department of Health Promotion Sciences, University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, AZ, USA.,Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Sarabeth Broder-Fingert
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nancy Byatt
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA.,Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA.,Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Stephenie Lemon
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, S5-828, 55 Lake Ave N, Worcester, MA, 01655, USA
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Workman B, Beck AF, Newman NC, Nabors L. Evaluation of a Program to Reduce Home Environment Risks for Children with Asthma Residing in Urban Areas. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:172. [PMID: 35010432 PMCID: PMC8750910 DOI: 10.3390/ijerph19010172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 06/14/2023]
Abstract
Pediatric asthma morbidity is often linked to challenges including poor housing quality, inability to access proper medical care, lack of medications, and poor adherence to medical regimens. Such factors also propagate known disparities, by race and income, in asthma-related outcomes. Multimodal home visits have an established evidence base in support of their use to improve such outcomes. The Collaboration to Lessen Environmental Asthma Risks (CLEAR) is a partnership between the Cincinnati Children's Hospital Medical Center and the local health department which carries out home visits to provide healthy homes education and write orders for remediation should code violations and environmental asthma triggers be identified. To assess the strengths and weaknesses of the program, we obtained qualitative feedback from health professionals and mothers of children recently hospitalized with asthma using key informant interviews. Health professionals viewed the program as a positive support system for families and highlighted the potential benefit of education on home asthma triggers and connecting families with services for home improvements. Mothers report working to correct asthma triggers in the home based on the education they received during the course of their child's recent illness. Some mothers indicated mistrust of the health department staff completing home visits, indicating a further need for research to identify the sources of this mistrust. Overall, the interviews provided insights into successful areas of the program and areas for program improvement.
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Affiliation(s)
- Brandon Workman
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267-0056, USA;
| | - Andrew F. Beck
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229-3026, USA;
| | - Nicholas C. Newman
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH 45267-0056, USA;
- Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229-3026, USA;
| | - Laura Nabors
- Department of Health Promotion and Education, University of Cincinnati, Cincinnati, OH 45221-0068, USA;
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Further Inspection: Integrating Housing Code Enforcement and Social Services to Improve Community Health. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212014. [PMID: 34831769 PMCID: PMC8623912 DOI: 10.3390/ijerph182212014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/25/2022]
Abstract
As a result of working inside homes, city housing inspectors witness hidden and serious threats to public health. However, systems to respond to the range of problems they encounter are lacking. In this study, we describe the impact and enabling environment for integrating a novel Social Service Referral Program within the Inspectional Services Department in Chelsea, MA. To evaluate the first eight months of the program, we used a mixed-methods approach combining quantitative data from 15 referrals and qualitative interviews with six key informants (inspectors, a case manager, and city leadership). The most common services provided to residents referred by inspectors were for fuel, food, and rent assistance; healthcare; hoarding; and homelessness prevention. Half of referred residents were not receiving other social services. Inspectors reported increased work efficiency and reduced psychological burden because of the program. Interviewees described how quality of life improved not only for referred residents but also for the surrounding neighborhood. A simple referral process that made inspectors’ jobs easier and a trusted, well-connected service provider funded to carry out the work facilitated the program’s uptake and impact. Housing inspectors’ encounters with residents present a unique opportunity to expand the public health impact of housing code enforcement.
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Chambers EC, Heller C, Fiori K, McAuliff K, Rehm CD. Chronic pediatric health conditions among youth living in public housing and receiving care in a large hospital system in Bronx, NY. Glob Pediatr Health 2020; 7:2333794X20971164. [PMID: 33241085 PMCID: PMC7672759 DOI: 10.1177/2333794x20971164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/06/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022] Open
Abstract
This study compared the prevalence of chronic pediatric health conditions for youth in public housing with youth not in public housing using clinical electronic health record (EHR) and housing data. Youth (ages 2-17 years) in a large urban health system were identified and categorized into two housing types—public housing (n = 10 770) and not in public housing (n = 84 883) by age (young childhood, middle childhood, young adolescence). The prevalence of some pediatric conditions was higher in public housing but varied by age. Disparities in health conditions among youth in public housing were more common in early adolescence: asthma (26.4 vs 18.6; P < .001); obesity (28.5 vs 24.6; P < .001); depression/anxiety (19.2 vs 17.3; P = .008); behavioral disorders (8.1 vs 5.3; P < .001). These results show that chronic pediatric conditions like asthma and obesity that lead to significant morbidity into adulthood are more common among youth living in public housing. However, this pattern is not consistent across all chronic conditions.
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Affiliation(s)
| | | | - Kevin Fiori
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore Health System, Bronx, NY, USA
| | | | - Colin D Rehm
- Albert Einstein College of Medicine, Bronx, NY, USA.,Montefiore Health System, Bronx, NY, USA
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Trivedi M, Patel J, Hoque S, Mizrahi R, Biebel K, Phipatanakul W, Lemon SC, Byatt N, Gerald LB, Rosal M, Pbert L. Alignment of stakeholder agendas to facilitate the adoption of school-supervised asthma therapy. Pediatr Pulmonol 2020; 55:580-590. [PMID: 31856415 PMCID: PMC7018546 DOI: 10.1002/ppul.24611] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/07/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND School-supervised inhaled corticosteroid (ICS) therapy improves pediatric asthma medication adherence, outcomes, and morbidity. However, school-supervised ICS therapy has not been widely adopted into practice. We developed Asthma Link™ as a sustainable, low-cost model of school-supervised asthma therapy, designed for real-world adoption. Initial outcomes of Asthma Link™ demonstrated a significant improvement in health outcomes. OBJECTIVE In this study, we examined the perspectives of Asthma Link™ participants to identify systems-level barriers and facilitators to refine the Asthma Link™ protocol and facilitate real-world uptake of school-supervised asthma therapy. METHODS Using qualitative research methods, we interviewed 29 participants in Asthma Link™ from 2016 to 2018. Semi-structured interviews were conducted over the phone. Interviews were transcribed and the transcripts were coded to identify major themes within and across stakeholder groups. RESULTS Stakeholders agreed on many facilitators for successful Asthma Link™ execution including the brief and easy to follow procedures and the perceived beneficial health impacts for children involved. Some of the barriers identified were deviations from the protocol and insurance companies denying coverage for two inhalers. However, the participants did propose solutions to address these barriers. CONCLUSION Asthma Link™ is a low-cost, sustainable model of school-supervised asthma therapy that leverages the established infrastructure and collaboration of medical providers, school staff, and families. In this study, we elicited the perspectives from these stakeholder groups and identified an agreement in several facilitators, barriers, and proposed solutions that will ultimately inform refinement of the program protocol and support real-world adoption of Asthma Link™ and other similar models.
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Affiliation(s)
- Michelle Trivedi
- Department of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Janki Patel
- Department of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Shushmita Hoque
- Department of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Raphael Mizrahi
- Department of Pediatric Pulmonology, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kathleen Biebel
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Wanda Phipatanakul
- Department of Asthma, Allergy, and Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Stephenie C Lemon
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Nancy Byatt
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Lynn B Gerald
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Milagros Rosal
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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