The Chicago Asthma Consortium: a community coalition targeting reductions in asthma morbidity

Asthma mitigation strategies: professional, charitable, and community coalitions

BACKGROUND

Asthma symptoms, severity, and mortality are known to be affected by personal, family, and neighborhood social factors. Many groups have become involved in asthma research, education, and activism in the past 20 years. This study explores the approaches to asthma taken by community-based organizations compared with those taken by other organizations that have a focus on asthma.

METHODS

Priorities in asthma research and intervention were assessed through interviews with representatives of urban community-based participatory research (CBPR) coalitions; interviews with staff from charities focused on asthma, allergy, or lung diseases; interviews with physicians and scientists studying and treating asthma; participation in community forums; and participant observation of urban asthma coalitions. Interviews and data analysis were conducted in 2008.

RESULTS

There are marked differences in priorities and approaches to asthma among experts in the field, organizations and coalitions at the national and local levels, and other stakeholders in asthma research and activism. CBPR coalitions are more likely than asthma-focused organizations to explore environmental and community-level structural factors that exacerbate asthma or complicate its management, while disease-focused organizations, especially physician specialty groups, place more emphasis on individual-level factors. CBPR coalitions have been particularly strong in producing the data needed to demonstrate that individual communities are affected by pollution hot spots or that local neighborhoods lack geographic access to affordable medical care, and in providing this data to improve local policy-making.

CONCLUSIONS

Because of its focus on structural rather than individual factors, CBPR has helped to broaden the debate on asthma beyond clinical care and education into social and environmental justice.

Are we closing the disparities gap? Small-area analysis of asthma in Chicago

Disparities in asthma outcomes in the Chicago area have been observed between geographic areas and ethnic and socioeconomic groups. As efforts to close this gap have moved beyond the initial characterization of the problem to implementation of concrete programs to address these disparities, objective measures of success are essential. We present a variety of data from the Chicago area to assess whether any improvement in previously reported disparities can be demonstrated. While some process outcomes such as medication usage have improved over time, death from asthma has failed to demonstrate an equivalent improvement. More importantly, the differential in asthma mortality and hospitalization rates between African Americans and European Americans has failed to close in the years following the release of the National Asthma Education and Prevention Program asthma guidelines.

The Latino paradox in neighborhood context: the case of asthma and other respiratory conditions

OBJECTIVES

Evidence indicates that foreign-born Latinos have a health advantage compared with US-born persons of the same socioeconomic status. An explanation for this paradox has remained elusive. We examined the extent to which this paradox exists for the prevalence of asthma and other respiratory conditions. We then explored the role of neighborhood social context in understanding any observed advantage. We invoked theories of social organization, collective efficacy, and the urban ethnic enclave.

METHODS

We combined data from the Project on Human Development in Chicago Neighborhoods Community Survey with 2 other data sources and used hierarchical generalized linear modeling techniques.

RESULTS

We found a distinctly graded effect for asthma and other breathing problems among foreign-born Latinos, depending on community composition. Foreign-born Latinos embedded in a neighborhood that had a high percentage of foreign-born residents experienced a significantly lower prevalence of asthma and other breathing problems; those in communities that had a low percentage of foreign-born residents had the highest prevalence overall (even when compared with African Americans).

CONCLUSIONS

Foreign-born Latinos have a respiratory health advantage only in enclave-like settings. Contexts such as these may provide the cohesiveness critical for effective prevention.

What explains community coalition effectiveness?: a review of the literature

Community coalitions have become popular vehicles for promoting health. Which factors make coalitions effective, however, is unclear. The study's aim was to identify coalition-building factors related to indicators of coalition effectiveness through a review of the empirical literature. Published articles from 1980 to 2004 that empirically examined the relationships among coalition-building factors and indicators of coalition effectiveness were reviewed. Two indicators of coalition effectiveness were examined: coalition functioning and community-wide changes. A two-phase strategy was employed to identify articles by reviewing citations from previous literature reviews and then searching electronic reference databases. A total of 1168 non-mutually exclusive citations were identified, their abstracts reviewed, and 145 unique full articles were retrieved. The review yielded 26 studies that met the selection criteria. Collectively, these studies assessed 26 indicators of coalition effectiveness, with 19 indicators (73%) measuring coalition functioning, and only two indicators (7%) measuring changes in rates of community-wide health behaviors. The 26 studies identified 55 coalition-building factors that were associated with indicators of coalition effectiveness. Six coalition-building factors were found to be associated with indicators of effectiveness in five or more studies: formalization of rules/procedures, leadership style, member participation, membership diversity, agency collaboration, and group cohesion. However, caution is warranted when drawing conclusions about these associations due to the wide variations in indicators of coalition effectiveness and coalition-building factors examined across relatively few studies, discrepancies in how these variables were measured, and the studies' reliance on cross-sectional designs.

Exploring neighborhood-level variation in asthma and other respiratory diseases: the contribution of neighborhood social context

OBJECTIVE

We explore differences in the prevalence of asthma and other respiratory diseases at the neighborhood level. In addition to traditional metrics of neighborhood structure (e.g., concentrated disadvantage, residential stability), we incorporate residents' evaluations of neighborhood context. We examine the extent to which indicators such as disorder (observable signs of physical and social decay) and collective efficacy (trust and shared expectations for beneficial community action) account for differences in the prevalence of asthma and other respiratory diseases.

METHODS

We examine 338 Chicago neighborhoods, combining 3 data sources from the 1990s: 1) the Metropolitan Chicago Information Center Metro Survey; 2) the Decennial Census; and 3) the Project on Human Development in Chicago Neighborhoods Community Survey. We use a multilevel statistical approach to disentangle neighborhood- from individual-level effects.

MEASUREMENTS

A survey-based response to whether a physician has diagnosed asthma, bronchitis, emphysema, or other breathing problems.

RESULTS

Findings indicate that individual- and neighborhood-level factors are associated with asthma/breathing problems. At the individual level, female gender, smoking, and a weight problem are positively associated with asthma/breathing problems, while Latino ethnicity is protective. At the neighborhood level, collective efficacy is protective against asthma/breathing problems. Residential stability is positively associated only when levels of collective efficacy are controlled.

CONCLUSIONS

Neighborhood context, particularly collective efficacy, may be an underlying factor that reduces vulnerability to asthma and other respiratory diseases. Collective efficacy may enhance the ability to garner health-relevant resources, eliminate environmental hazards that trigger asthma, and promote communication among residents which, in turn, enables dissemination of information relevant to respiratory ailments.

Trends in emergency department asthma care in metropolitan Chicago: results from the Chicago Asthma Surveillance Initiative

STUDY OBJECTIVE

The purpose of this study was to assess trends in emergency department (ED) asthma care in a single large community and to address how these trends meet expectations of national guidelines for asthma care.

DESIGN AND SETTING

This study is based on a repeated cross-sectional, self-administered survey of ED directors (or designees) in the Chicago area.

PARTICIPANTS

Fifty-one EDs that responded to both the 1996-1997 and 2000 surveys comprise the database for this study.

RESULTS

Areas of significant improvement from 1996-1997 to 2000 include reduction in the use of theophylline (10.1% vs 3.1%, p < 0.0001), increased use of systemic steroid prescriptions at discharge (57.7% vs 77.2%, p < 0.0001), decreased use of arterial blood gas (ABG) analyses as part of the initial patient assessment (10.2% vs 4.5%, p = 0.02) and to document improvement after treatments (18.8% vs 8.9%, p = 0.03) and increased use of pulse oximetry as part of the initial patient assessment (95.1% vs 98.1%, p = 0.05). Areas of significant worsening of asthma care from 1996-1997 to 2000 include reduction in the use of ABG analyses in the assessment of severe cases (71.5% vs 47.5%, p < 0.0001), decreased use of instructions to inform patients what to do in the event of inability to attend their follow-up appointment (94.4% vs 38.9%, p = 0.0004), and decreased use of peak expiratory flow rate measurements to document improvement after treatments (82.7% vs 78.6%, p = 0.04).

CONCLUSIONS

From 1996-1997 to 2000, ED asthma care in metropolitan Chicago has improved in some areas and worsened in others. However, most aspects of asthma care have continued to fall short of national asthma guidelines. The lack of overall improvement with the current widespread knowledge of national guidelines suggests that a dissemination strategy of medical education by itself is not sufficient to improve ED asthma care.

The Chicago Asthma Surveillance Initiative: a community-based approach to understanding asthma care

Nearly all of the asthma surveillance literature focuses on national-, regional-, or state-based estimates of prevalence, health-care utilization (specifically hospitalizations, emergency department, and ambulatory care visits), and mortality. Although these are important events, they reveal little about asthma's impact at the community level and provide little information that could be used to design specific interventions for improving clinical outcomes. A useful representation of asthma care across a community could guide an effective community response to the burden of asthma. The goal of the Chicago Asthma Surveillance Initiative (CASI) is to develop a community-wide surveillance program that characterizes and monitors asthma care in the Chicago area, beyond existing public health surveillance. To accomplish this, CASI surveyed Chicago-area hospitals, emergency departments, primary care physicians, specialty care physicians, pharmacists, managed care organizations, the general public, and persons or families affected by asthma to learn about asthma care and its outcomes. A variety of techniques (including brochures, slide kits, and the Internet) were used to achieve rapid public dissemination of study findings. The value of this comprehensive community-based data surveillance effort will rest on how the community uses this information to stimulate new efforts to improve asthma care and reduce untoward outcomes.

A survey of asthma care in managed care organizations: results from the Chicago Asthma Surveillance Initiative

INTRODUCTION

Managed care, both via staff model health maintenance plans and nonstaff model plans, has become a major source of health-care funding in the United States. However, very little is known about the asthma-specific products and services offered by these plans. The purpose of this study is to examine the asthma-specific products and services offered by managed care within the Chicago area.

METHODS

Between December 1997 and February 1998, a self-administered survey was mailed to the medical directors of the 19 managed care organizations (MCOs) in the Chicago area. The survey covered the following content areas: general characteristics of the MCOs, asthma-related services, monitoring of asthma care, and asthma-related quality improvement efforts. The medical directors were asked to respond separately for staff model capitated plans, nonstaff model capitated plans, and noncapitated plans.

RESULTS

Responses were received from 13 of the 19 eligible Chicago-area MCOs (a response rate of 68.4%). Three of the responding MCOs (23.1%) offered a staff model plan, 11 (84.6%) offered a nonstaff model capitated plan, and 6 offered some type of noncapitated plan. Asthma education programs, although available in all plan types, were offered much less frequently in the nonstaff model capitated and noncapitated plans, 36.4% and 33.3%, respectively. Asthma case management programs were also available in some, but not all of the health plans. Only 54.5% of the nonstaff model capitated health plans promoted the use of asthma practice guidelines. Among the responding MCOs, asthma quality improvement efforts related to National Committee on Quality Assurance accreditation were infrequent in 1995. Sixty-one percent of the MCOs reported that program development for improving asthma care was a very high priority relative to programs for other health conditions.

CONCLUSION

The results of this study suggest that many, but not all, of the basic elements of asthma care services are offered by the MCOs in the Chicago area. Findings from this study also suggest ways in which asthma-related product and service delivery might be changed to improve outcomes for asthma in this community.