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

Collaborative Integration of Community Health Workers in Hospitals and Health Centers to Reduce Pediatric Asthma Disparities: A Quality Improvement Program Evaluation

To address pediatric asthma disparities on the South Side of Chicago, a community health worker (CHW) home visiting intervention was implemented collaboratively by academic institutions and community based health centers. This evaluation assessed the effectiveness of this longitudinal quality improvement CHW intervention in reducing asthma morbidity and healthcare utilization. All patients aged 2-18 who met the high-risk clinical criteria in outpatient settings or those who visited the ED due to asthma were offered the program. A within-subject study design analyzed asthma morbidity and healthcare utilization at baseline and follow-up. Multivariable mixed-effects regression models, adjusted for baseline demographic and asthma characteristics, were used to assess changes over time. Among 123 patients, the average age was 8.8 (4.4) years, and 89.3% were non-Hispanic black. Significant reductions were observed in the average daytime symptoms days (baseline 4.1 days and follow-up 1.6 days), night-time symptoms days (3.0 days and 1.2 days), and days requiring rescue medication (4.1 days and 1.6 days) in the past two weeks (all p < 0.001). The average number of emergency department visits decreased from 0.92 one year before to 0.44 one year after program participation, a 52% reduction (p < 0.001). No significant difference was found in hospital admissions. These results support the use of a collaborative approach to implement the CHW home visiting program as part of standard care for pediatric asthma patients in urban settings. This approach has the potential to reduce asthma disparities and underscores the valuable role of CHWs within the clinical care team.

Community Interventions for Childhood Asthma ED Visits and Hospitalizations: A Systematic Review

A systematic review of interventions in community environments found significant reductions in childhood asthma exacerbations leading to emergency department visits and hospitalizations.

BACKGROUND AND OBJECTIVES

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions.

METHODS

Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays).

RESULTS

Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination (n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) (n = 8), home-based (n = 6), and community-based health services (n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis.

CONCLUSIONS

Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Pediatric Inner-City Asthma

Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.

A randomized controlled trial of a community health worker delivered home-based asthma intervention to improve pediatric asthma outcomes

OBJECTIVE

The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-based Wee Wheezers asthma education program on asthma symptoms among children with persistent asthma.

METHODS

In this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed.

RESULTS

At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers.

CONCLUSION

Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.

Community Health Workers' Role in Supporting Pediatric Asthma Management: A Review

Objective

Community Health Workers (CHWs) have been effective in improving health outcomes in vulnerable communities by providing health education and management services. We review CHW-led asthma education and management interventions for children and their families. Next, we describe the selection and training of CHWs in pediatric asthma management in the Rhode Island Integrated Response Asthma Care Implementation Program (RI-AIR).

Methods

We queried the MEDLine, Cochrane, PubMed, and EMBASE databases with keywords ("community health worker", "asthma", "health worker", "lay worker", "pediatric", "child", and "childhood") from inception until September 2019. Criteria for study inclusion included: published in English, conducted in the United States, approved with an ethics notification, published in peer-reviewed journal, and involved CHWs as the interventionists. The initial search identified 216 manuscripts. Fifteen studies met criteria for inclusion.

Results

CHWs provide asthma management and education services, including home environmental trigger assessments, strategies to reduce environmental trigger exposure, resource linkage, and community referrals. We describe RI-AIR, and its CHW-led asthma education and management interventions.

Conclusions

CHWs are effective and vital supports for positive asthma outcomes. More research is needed to guide models of intervention using CHWs, specifically addressing integration in interdisciplinary teams, training, and reimbursement for CHW services.

Implications for Impact Statement

CHWs are effective in helping children with asthma and their families learn to manage asthma. It is important to develop programs that prepare CHWs to work with other medical professionals and health care models to pay for their services.

Design of a home-based intervention for Houston-area African-American adults with asthma: Methods and lessons learned from a pragmatic randomized trial

A growing body of evidence demonstrates that home-based, multicomponent interventions can effectively reduce exposures to asthma triggers and decrease asthma symptoms. However, few of these studies have targeted adults. To address this and other research gaps, we designed and implemented a pragmatic randomized clinical trial, the Houston Home-based Integrated Intervention Targeting Better Asthma Control (HIITBAC) for African Americans, to assess the effectiveness of a home-based intervention to improve asthma control and quality of life in African-American adults-a population disproportionately affected by asthma. The primary goals were to help participants reduce allergens and irritants in their homes and better manage their disease through knowledge, improved medication use, and behavior change. HIITBAC had two groups: clinic-only and home-visit groups. Both groups received enhanced clinical care, but the home-visit group also received a detailed home assessment and four additional home visits spaced over roughly one year. We recruited 263 participants. Of these, 152 (57.8%) were recruited through electronic health record data, 51 (19.4%) through Emergency Medical Services data, and 60 (22.8%) through other efforts (e.g., emergency departments, community events, outreach). Seventy participants (26.6%) were lost to follow up, substantially more in the home-visit than in the clinic-only group. We describe the HIITBAC methodology and cohort, discuss lessons learned about recruitment and retention, and highlight adaptations we implemented to address these lessons.

The Role of Environmental Controls in Managing Asthma in Lower-Income Urban Communities

Children living in lower-income urban communities are at much greater risk of developing asthma, going to the emergency department for an asthma attack and being hospitalized for asthma than children living in upper- and middle-income communities. For many asthmatic children living in urban communities, especially those with greater morbidity, the allergic pathway is important in the etiology of the disease. The stages of developing allergic disease can be divided into the onset of allergic sensitization, development of allergic disease and subsequent exacerbations, and it is useful to consider the relevance of interventions at each of these stages. Indoor allergens and environmental exposures are a major contributor to allergic disease, particularly among lower socioeconomic status, urban, minority communities. These exposures include allergens, environmental tobacco smoke, combustion by-products, and mold, all of which can play an important role in asthma progression as well as morbidity. These exposures are often not found in isolation and thus these concomitant exposures need to be considered when conducting environmental interventions. There have been numerous studies looking at both primary and tertiary prevention strategies and the impact on allergic sensitization and asthma with varied results. While the outcomes of these studies have been mixed, what has emerged is the need for tertiary interventions to be targeted to the individual and to reduce all relevant exposures to which an asthmatic child is exposed and sensitized. In addition, effective intervention strategies must also consider other social determinants of asthma morbidity impacting low socioeconomic, urban communities.

The Role of Home Environments in Allergic Disease

Allergic diseases are surprisingly common, chronic health conditions. The primary location where the vast majority of people are exposed to allergens and other substances is in their home. This means it is important to understand home environments and how a home's systems function and interact-and that how we occupy these spaces plays a crucial role in both environmental exposure and management of allergic disease. This review provides an overview of what is understood about home environmental exposure and its impact on our health, and proposes a systematic process for using a patient's environmental history to develop individualized, manageable and cost-effective recommendations. Once occupant-related information has been gathered, a home environmental exposure assessment should be performed focused on identifying the relationships between any identified sources of contaminants and the housing systems, and conditions that may be contributing to exposure. The results and recommendations from this assessment can then be used to guide exposure-reduction efforts by patients and/or their caregivers in an effort to improve disease management. In this review, we'll discuss three different types of home interventions-active, which must be routinely performed by the patient and/or caregiver, passive, which are interventions that work without routine, direct interaction from the homeowner, and behavioral changes in how the home environment is cleaned and maintained for long-term reduction of allergens. In this review, and others evaluated for this discussion, a significant number of home environmental assessment and intervention programs were shown to be cost effective, with the majority of programs showing a net positive return on investment. It is important to recognize that to be cost effective, the level and intensity of services offered through home visit programs need be stratified, based on the estimated health risks of the patient, in order to tailor the assessment and target the interventions to a patient's needs while maximizing cost effectiveness.

Pediatric Inner-City Asthma

Inner-city children with asthma are known to have high disease mortality and morbidity. Frequently, asthma in this high-risk population is difficult to control and more severe in nature. Several factors, including socioeconomic hardship, ability to access to health care, adherence to medication, exposure to certain allergens, pollution, crowd environment, stress, and infections, play an important role in the pathophysiology of inner-city asthma. Comprehensive control of home allergens and exposure to tobacco smoke, the use of immune based therapies, and school-based asthma programs have shown promising results in asthma control in this population.

Inner-City Asthma in Children

Asthma in inner-city children is often severe and difficult to control. Residence in poor and urban areas confers increased asthma morbidity even after adjusting for ethnicity, age, and gender. Higher exposure to household pests, such as cockroaches and mice, pollutants and tobacco smoke exposure, poverty, material hardship, poor-quality housing, differences in health care quality, medication compliance, and heath care access also contribute to increased asthma morbidity in this population. Since 1991, the National Institutes of Allergy and Infectious Diseases established research networks: the National Cooperative Inner-City Asthma Study (NCICAS), the Inner-City Asthma Study (ICAS), and the Inner-City Asthma Consortium (ICAC), to improve care for this at risk population. The most striking finding of the NCICAS is the link between asthma morbidity and the high incidence of allergen sensitization and exposure, particularly cockroach. The follow-up ICAS confirmed that reductions in household cockroach and dust mite were associated with reduction in the inner-city asthma morbidity. The ICAC studies have identified that omalizumab lowered fall inner-city asthma exacerbation rate; however, the relationship between inner-city asthma vs immune system dysfunction, respiratory tract infections, prenatal environment, and inner-city environment is still being investigated. Although challenging, certain interventions for inner-city asthma children have shown promising results. These interventions include family-based interventions such as partnering families with asthma-trained social workers, providing guidelines driven asthma care as well as assured access to controller medication, home-based interventions aim at elimination of indoor allergens and tobacco smoke exposure, school-based asthma programs, and computer/web-based asthma programs.

Relationships between home ventilation rates and respiratory health in the Colorado Home Energy Efficiency and Respiratory Health (CHEER) study

BACKGROUND

As societies adopt green building practices to reduce energy expenditures and emissions that contribute to climate change, it is important to consider how such building design changes influence health. These practices typically focus on reducing air exchange rates between the building interior and the outdoor environment to minimize energy loss, the health effects of which are not well characterized. This study aims to evaluate the relationship between air exchange rates and respiratory health in a multi-ethnic population living in low-income, urban homes.

METHODS

The Colorado Home Energy Efficiency and Respiratory Health (CHEER) study is a cross-sectional study that enrolled 302 people in 216 non-smoking, low-income single-family homes, duplexes and town-homes from Colorado's Northern Front Range. A blower door test was conducted and the annual average air exchange rate (AAER) was estimated for each home. Respiratory health was assessed using a structured questionnaire based on standard instruments. We estimated the association between AAER and respiratory symptoms, adjusting for relevant confounders.

RESULTS

Air exchange rates in many homes were high compared to prior studies (median 0.54 air changes per hour, range 0.10, 2.17). Residents in homes with higher AAER were more likely to report chronic cough, asthma and asthma-like symptoms, including taking medication for wheeze, wheeze that limited activities and dry cough at night. Allergic symptoms were not associated with AAER in any models. The association between AAER and asthma-like symptoms was stronger for households located in areas with high potential exposure to traffic related pollutants, but this was not consistent across all health outcomes.

CONCLUSIONS

While prior studies have highlighted the potential hazards of low ventilation rates in residences, this study suggests high ventilation rates in single-family homes, duplexes and town-homes in urban areas may also have negative impacts on respiratory health, possibly due to the infiltration of outdoor pollutants.

Enhancing Early Childhood Mental Health Primary Care Services: Evaluation of MA Project LAUNCH

Objectives The purpose of this study was to evaluate the efficacy of an innovative early childhood mental health intervention, Massachusetts Project LAUNCH. Early childhood mental health clinicians and family partners (paraprofessionals with lived experience) were embedded within community pediatric medical homes. Methods A longitudinal study design was used to test the hypotheses that (1) children who received services would experience decreased social, emotional and behavioral problems over time and (2) caregivers' stress and depressive symptoms would decrease over time. Families who were enrolled in services and who consented to participate in the evaluation study were included in analyses (N = 225). Individual growth models were used to test longitudinal effects among MA LAUNCH participants (children and caregivers) over three time points using screening tools. Results Analyses showed that LAUNCH children who scored in age-specific clinically significant ranges of social, emotional and behavioral problems at Time 1 scored in the normal range on average by Time 3. Caregivers' stress and depressive symptoms also declined across the three time points. Results support hypotheses that the LAUNCH intervention improved social and emotional health for children and caregivers. Conclusions for Practice This study led to sustainability efforts, an expansion of the model to three additional communities across the state and development of an online toolkit for other communities interested in implementation.

Chemical exposures in recently renovated low-income housing: Influence of building materials and occupant activities

Health disparities in low-income communities may be linked to residential exposures to chemicals infiltrating from the outdoors and characteristics of and sources in the home. Indoor sources comprise those introduced by the occupant as well as releases from building materials. To examine the impact of renovation on indoor pollutants levels and to classify chemicals by predominant indoor sources, we collected indoor air and surface wipes from newly renovated "green" low-income housing units in Boston before and after occupancy. We targeted nearly 100 semivolatile organic compounds (SVOCs) and volatile organic compounds (VOCs), including phthalates, flame retardants, fragrance chemicals, pesticides, antimicrobials, petroleum chemicals, chlorinated solvents, and formaldehyde, as well as particulate matter. All homes had indoor air concentrations that exceeded available risk-based screening levels for at least one chemical. We categorized chemicals as primarily influenced by the occupant or as having building-related sources. While building-related chemicals observed in this study may be specific to the particular housing development, occupant-related findings might be generalizable to similar communities. Among 58 detected chemicals, we distinguished 25 as primarily occupant-related, including fragrance chemicals 6-acetyl-1,1,2,4,4,7-hexamethyltetralin (AHTN) and 1,3,4,6,7,8-hexahydro-4,6,6,7,8,8-hexamethylcyclopenta[g]-2-benzopyran (HHCB). The pre- to post-occupancy patterns of the remaining chemicals suggested important contributions from building materials for some, including dibutyl phthalate and xylene, whereas others, such as diethyl phthalate and formaldehyde, appeared to have both building and occupant sources. Chemical classification by source informs multi-level exposure reduction strategies in low-income housing.

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma-implications for home environmental intervention in asthma prevention and management

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

Housing code violation density associated with emergency department and hospital use by children with asthma

Local agencies that enforce housing policies can partner with the health care system to target pediatric asthma care. These agencies retain data that can be used to pinpoint potential clusters of high asthma morbidity. We sought to assess whether the density of housing code violations in census tracts-the in-tract asthma-relevant violations (such as the presence of mold or cockroaches) divided by the number of housing units-was associated with population-level asthma morbidity and could be used to predict a hospitalized patient's risk of subsequent morbidity. We found that increased density in housing code violations was associated with population-level morbidity independent of poverty, and that the density explained 22 percent of the variation in rates of asthma-related emergency department visits and hospitalizations. Children who had been hospitalized for asthma had 1.84 greater odds of a revisit to the emergency department or a rehospitalization within twelve months if they lived in the highest quartile of housing code violation tracts, compared to those living in the lowest quartile. Integrating housing and health data could highlight at-risk areas and patients for targeted interventions.

Evaluation of a Home-Based Environmental and Educational Intervention to Improve Health in Vulnerable Households: Southeastern Pennsylvania Lead and Healthy Homes Program

This evaluation examined whether participation in a home-based environmental educational intervention would reduce exposure to health and safety hazards and asthma-related medical visits. The home intervention program focused on vulnerable, low-income households, where children had asthma, were at risk for lead poisoning, or faced multiple unsafe housing conditions. Home visitors conducted two home visits, two months apart, consisting of an environmental home assessment, Healthy Homes education, and distribution of Healthy Homes supplies. Measured outcomes included changes in participant knowledge and awareness of environmental home-based hazards, rate of children’s asthma-related medical use, and the presence of asthma triggers and safety hazards. Analysis of 2013–2014 baseline and post-intervention program data for a cohort of 150 families revealed a significantly lower three-month rate (p < 0.05) of children’s asthma-related doctor visits and hospital admissions at program completion. In addition, there were significantly reduced reports of the presence of home-based hazards, including basement or roof leaks (p = 0.011), plumbing leaks (p = 0.019), and use of an oven to heat the home (p < 0.001). Participants’ pre- and post- test scores showed significant improvement (p < 0.05) in knowledge and awareness of home hazards. Comprehensive home interventions may effectively reduce environmental home hazards and improve the health of asthmatic children in the short term.

Effective education parameters for trigger remediation in underserved children with asthma: A systematic review

OBJECTIVES

The prevalence of asthma is highest in minority children living in urban areas. Pediatric asthma research has focused on self-management education and trigger remediation using a multi-trigger, multi-component educational intervention approach. The purpose of this systematic review was to identify common educational parameters of these proposed interventions. The review also sought to identify which clinical outcomes improved with multi-trigger, multi-component educational interventions.

DATA SOURCES

PubMed, SCOPUS and ProQuest Dissertations were searched between 2000 to 2014 using the following terms: asthma; urban population or poverty area; environmental remediation; health education; allergens or dust mites or cockroaches or mold or mice or rats.

STUDY SELECTIONS

Studies were included if they met the following criteria: 1) participants were minority children identified as underserved; 2) there was a multi-trigger and multi-component intervention; 3) asthma severity was classified as persistent; and 4) asthma control was classified as not well controlled.

RESULTS

A total of 531 articles were retrieved of which 17 met the inclusion criteria. The interventions lacked consistency in their explanation. Most studies were vague in reporting pedagogical methods and educational content. Few studies reported a theoretical framework to guide their approach. Over half the studies did not report a learning assessment nor health literacy of the caregiver or the child with asthma. Yet all of the findings demonstrated statistically significant results in some or all of their primary outcomes.

CONCLUSION

Overall, the research lacked clarity in the approach to impact asthma outcomes and reduces the opportunity to substantiate the findings through replication.

Making Homes Healthy: International Code Council Processes and Patterns

CONTEXT

Americans spend more than 90% of their time indoors, so it is important that homes are healthy environments. Yet many homes contribute to preventable illnesses via poor air quality, pests, safety hazards, and others. Efforts have been made to promote healthy housing through code changes, but results have been mixed. In support of such efforts, we analyzed International Code Council's (ICC) building code change process to uncover patterns of content and context that may contribute to successful adoptions of model codes.

OBJECTIVE

Discover patterns of facilitators and barriers to code amendments proposals.

DESIGN

Mixed methods study of ICC records of past code change proposals. N = 2660.

SETTING

N/A.

PARTICIPANTS

N/A.

MAIN OUTCOME MEASURE(S)

There were 4 possible outcomes for each code proposal studied: accepted as submitted, accepted as modified, accepted as modified by public comment, and denied.

RESULTS

We found numerous correlates for final adoption of model codes proposed to the ICC. The number of proponents listed on a proposal was inversely correlated with success. Organizations that submitted more than 15 proposals had a higher chance of success than those that submitted fewer than 15. Proposals submitted by federal agencies correlated with a higher chance of success. Public comments in favor of a proposal correlated with an increased chance of success, while negative public comment had an even stronger negative correlation.

CONCLUSIONS

To increase the chance of success, public health officials should submit their code changes through internal ICC committees or a federal agency, limit the number of cosponsors of the proposal, work with (or become) an active proposal submitter, and encourage public comment in favor of passage through their broader coalition.

Health Benefits of Green Public Housing: Associations With Asthma Morbidity and Building-Related Symptoms

OBJECTIVES

We examined associations of several health outcomes with green and conventional low-income housing, where the prevalence of morbidities and environmental pollutants is elevated.

METHODS

We used questionnaires and a visual inspection to compare sick building syndrome (SBS) symptoms and asthma-related morbidity among residents in multifamily units in Boston, Massachusetts, between March 2012 and May 2013. Follow-up was approximately 1 year later.

RESULTS

Adults living in green units reported 1.35 (95% confidence interval [CI] = 0.66, 2.05) fewer SBS symptoms than those living in conventional (control) homes (P < .001). Furthermore, asthmatic children living in green homes experienced substantially lower risk of asthma symptoms (odds ratio [OR] = 0.34; 95% CI = 0.12, 1.00), asthma attacks (OR = 0.31; 95% CI = 0.11, 0.88), hospital visits (OR = 0.24; 95% CI = 0.06, 0.88), and asthma-related school absences (OR = 0.21; 95% CI = 0.06, 0.74) than children living in conventional public housing.

CONCLUSIONS

Participants living in green homes had improved health outcomes, which remained consistent over the study period. Green housing may provide a significant value in resource-poor settings where green construction or renovation could simultaneously reduce harmful indoor exposures, promote resident health, and reduce operational costs.

Inner city asthma

The inner city has long been recognized as an area of high asthma morbidity and mortality. A wide range of factors interact to create this environment. These factors include well-recognized asthma risk factors that are not specific to the inner city, the structure and delivery of health care, the location and function of the urban environment, and social inequities. In this article, these facets are reviewed, and successful and unsuccessful interventions are discussed, to understand what is needed to solve this problem.

Homes of low-income minority families with asthmatic children have increased condition issues

The home is increasingly associated with asthma. It acts both as a reservoir of asthma triggers and as a refuge from seasonal outdoor allergen exposure. Racial/ethnic minority families with low incomes tend to reside in neighborhoods with low housing quality. These families also have higher rates of asthma. This study explores the hypothesis that black and Latino urban households with asthmatic children experienced more home mechanical, structural condition-related areas of concern than white households with asthmatic children. Participant families (n = 140) took part in the Kansas City Safe and Healthy Homes Program, had at least one asthmatic child, and met income qualifications of no more than 80% of local median income; many were below 50%. Families self-identified their race. Homes were assessed by environmental health professionals using a standard set of criteria and a specific set of on-site and laboratory sampling and analyses. Homes were given a score for areas of concern between 0 (best) and 53 (worst). The study population self-identified as black (46%), non-Latino white (26%), Latino (14.3%), and other (12.9%). Mean number of areas of concern were 18.7 in Latino homes, 17.8 in black homes, 13.3 in other homes, and 13.2 in white homes. Latino and black homes had significantly more areas of concern. White families were also more likely to be in the upper portion of the income. In this set of 140 low-income homes with an asthmatic child, households of minority individuals had more areas of condition concerns and generally lower income than other families.

Indoor air quality in green vs conventional multifamily low-income housing

Indoor air quality is an important predictor of health, especially in low-income populations. It is unclear how recent trends in "green" building affect the indoor exposure profile. In two successive years, we conducted environmental sampling, home inspections, and health questionnaires with families in green and conventional (control) apartments in two public housing developments. A subset of participants was followed as they moved from conventional to green or conventional to conventional housing. We measured particulate matter less than 2.5 μm aerodynamic diameter (PM2.5), formaldehyde, nitrogen dioxide (NO2), nicotine, carbon dioxide (CO2), and air exchange rate (AER) over a seven-day sampling period coincident with survey administration. In multivariate models, we observed 57%, 65%, and 93% lower concentrations of PM2.5, NO2, and nicotine (respectively) in green vs control homes (p=0.032, p<0.001, p=0.003, respectively), as well as fewer reports of mold, pests, inadequate ventilation, and stuffiness. Differences in formaldehyde and CO2 were not statistically significant. AER was marginally lower in green buildings (p=0.109). Participants in green homes experienced 47% fewer sick building syndrome symptoms (p<0.010). We observed significant decreases in multiple indoor exposures and improved health outcomes among participants who moved into green housing, suggesting multilevel housing interventions have the potential to improve long-term resident health.