Adapting and implementing an evidence-based asthma counseling intervention for resource-poor populations

Racial Health Equity and Social Needs Interventions: A Review of a Scoping Review

IMPORTANCE

Social needs interventions aim to improve health outcomes and mitigate inequities by addressing health-related social needs, such as lack of transportation or food insecurity. However, it is not clear whether these studies are reducing racial or ethnic inequities.

OBJECTIVE

To understand how studies of interventions addressing social needs among multiracial or multiethnic populations conceptualize and analyze differential intervention outcomes by race or ethnicity.

EVIDENCE REVIEW

Sources included a scoping review of systematic searches of PubMed and the Cochrane Library from January 1, 1995, through November 29, 2021, expert suggestions, and hand searches of key citations. Eligible studies evaluated interventions addressing social needs; reported behavioral, health, or utilization outcomes or harms; and were conducted in multiracial or multiethnic populations. Two reviewers independently assessed titles, abstracts, and full text for inclusion. The team developed a framework to assess whether the study was "conceptually thoughtful" for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racism) and whether analyses were "analytically informative" for advancing racial health equity research (ie, examined differential intervention impacts by race or ethnicity).

FINDINGS

Of 152 studies conducted in multiracial or multiethnic populations, 44 studies included race or ethnicity in their analyses; of these, only 4 (9%) were conceptually thoughtful. Twenty-one studies (14%) were analytically informative. Seven of 21 analytically informative studies reported differences in outcomes by race or ethnicity, whereas 14 found no differences. Among the 7 that found differential outcomes, 4 found the interventions were associated with improved outcomes for minoritized racial or ethnic populations or reduced inequities between minoritized and White populations. No studies were powered to detect differences.

CONCLUSIONS AND RELEVANCE

In this review of a scoping review, studies of social needs interventions in multiracial or multiethnic populations were rarely conceptually thoughtful for understanding root causes of racial health inequities and infrequently conducted informative analyses on intervention effectiveness by race or ethnicity. Future work should use a theoretically sound conceptualization of how race (as a proxy for racism) affects social drivers of health and use this understanding to ensure social needs interventions benefit minoritized racial and ethnic groups facing social and structural barriers to health.

Wind disasters adaptation in cities in a changing climate: A systematic review

Wind-related disasters will bring more devastating consequences to cities in the future with a changing climate, but relevant studies have so far provided insufficient information to guide adaptation actions. This study aims to provide an in-depth elaboration of the contents discussed in open access literature regarding wind disaster adaptation in cities. We used the Latent Dirichlet Allocation (LDA) to refine topics and main contents based on 232 publications (1900 to 2019) extracted from Web of Science and Scopus. We conducted a full-text analysis to filter out focal cities along with their adaptation measures. The results show that wind disaster adaptation research in cities has formed a systematic framework in four aspects: 1) vulnerability and resilience of cities, 2) damage evaluation, 3) response and recovery, and 4) health impacts of wind disaster. Climate change is the background for many articles discussing vulnerability and adaptation in coastal areas. It is also embedded in damage evaluation since it has the potential to exacerbate disaster consequences. The literature is strongly inclined towards more developed cities such as New York City and New Orleans, among which New York City associated with Hurricane Sandy ranks first (38/232). Studies on New York City cover all the aspects, including the health impacts of wind disasters which are significantly less studied now. Distinct differences do exist in the number of measures regarding the adaptation categories and their subcategories. We also find that hard adaptation measures (i.e., structural and physical measures) are far more popular than soft adaptation measures (i.e., social and institutional measures). Our findings suggest that policymakers should pay more attention to cities that have experienced major wind disasters other than New York. They should embrace the up-to-date climate change study to defend short-term disasters and take precautions against long-term changes. They should also develop hard-soft hybrid adaptation measures, with special attention on the soft side, and enhance the health impact study of wind-related disasters.

Impact of Hurricanes on Children With Asthma: A Systematic Literature Review

Following hurricanes, there can be increases in exacerbations of chronic diseases, such as asthma. Asthma is common among children, and many asthma exacerbations can be prevented. This systematic literature review assessed literature describing the impact of hurricanes on children with asthma in the United States. Medline, Embase, Global Health, PubMed, and Scopus databases were searched for peer-reviewed, English-language articles published January 1990 to June 2019 that described the effect of a hurricane on children with asthma. This search identified 212 articles; 8 met inclusion criteria. All 8 were related to Hurricane Katrina, but research questions and study design varied. Articles included information on asthma after hurricanes from cross-sectional surveys, retrospective chart review, and objective clinical testing. Four articles described discontinuity in health insurance, asthma-related health care, or asthma medication use; and 3 articles examined the relationship between mold exposure and asthma symptoms and reported varying results. The eighth study quantified the burden of asthma among people visiting mobile medical units but did not describe factors associated with asthma symptoms. These results highlight opportunities for future research (eg, on more recent hurricanes) and disaster preparedness planning (eg, strategies to prevent health-care discontinuity among children with asthma).

A Community-Based Participatory Research Approach to Hurricane Katrina: When Disasters, Environmental Health Threats, and Disparities Collide

In 2005, Hurricane Katrina resulted in long-term flooding of 80% of New Orleans, Louisiana. Mold-infested homes gave rise to concerns about increased childhood asthma. To address these concerns, a diverse community-academic partnership used a community-based participatory research (CBPR) approach to implement the Head-off Environmental Asthma in Louisiana (HEAL) study in 2007.The study examined the relationship between post-Katrina mold and other environmental exposures and asthma morbidity, while testing an asthma counselor (AC) intervention. Both the AC intervention and the CBPR approach were effectively implemented in the postdisaster setting. However, homes had lower levels of mold and other allergens than expected, possibly because of the timing of environmental sampling. Also, HEAL illustrated the vulnerability of the study community, especially to the interconnected threats of health disparities, environmental health stressors, and disasters.We examine the implications of these threats for public health science, policy, and practice, not only through the lens of Hurricane Katrina but also for future disasters faced by communities in the Gulf Coast and nationally.

Effect of Sociodemographics, Health-Related Problems, and Family Structure on Chronic Absenteeism Among Children

BACKGROUND

From 5 to 7.5 million schoolchildren are chronically absent, defined as missing ≥15 days of school within a year. Students miss schools due to various reasons such as health, socioeconomic status, and environmental factors. We examined child's health and behavior, family structure, and sociodemographics to understand chronic absenteeism.

METHODS

The population included children ages 6 to 17 years from the Medical Expenditure Panel Survey years 2008-2013. Multivariable logistic regressions were used to identify the risk factors of chronic absenteeism, adjusting for the complex sampling design.

RESULTS

Among sociodemographic variables, age ≥14 years, race/ethnicity, lower-income family, public health insurance, US born, and speaking English at home were associated with absenteeism. Asians, Mexican Hispanics, and blacks have lower absenteeism than whites. Among health-related variables, children using an inhaler for asthma, having behavioral problems, and less healthy than other children were more likely to be chronically absent. Among family variables, a smaller family size was a risk factor for absenteeism.

CONCLUSIONS

Asthma and behavioral problems were highly associated with chronic absenteeism. The identification of children at risk for chronic absenteeism will help the educational professionals identify the barriers to academic achievements and develop integrated educational interventions and policies to support disadvantaged children.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Successes and Lessons Learned From Implementing Community Health Worker Programs in Community-Based and Clinical Settings: Insights From the Gulf Coast

CONTEXT

Community health workers (CHWs) are an increasingly viable component of the American health system. While organizations may be interested in incorporating CHWs into the health care workforce, there are challenges to doing so.

OBJECTIVE

This study characterizes the successes and lessons learned from implementing new CHW programs in clinical and community-based settings in 4 US Gulf states.

DESIGN

Semistructured interviews were conducted with CHWs and their supervisors.

SETTING

Interviews were conducted with participants in 16 community-based organizations and federally qualified health centers located in coastal counties and parishes of Louisiana, Florida, Alabama, and Mississippi.

PARTICIPANTS

Study participants consisted of 22 CHWs and 17 CHW supervisors.

RESULTS

Although most challenges and strategies were reported by participants working in both clinical and community-based settings, some were workplace-specific. Participants from predominantly clinical settings described the importance of strengthening organizational cohesion and coordination, whereas participants from community-based participants discussed the need for specialized training for CHWs. In both work environments, participants indicated that CHW functioning was constrained by limited organizational resources, difficulty accessing the client population, and limited knowledge regarding the CHW's scope of practice. Strategies to improve CHW functioning in both settings included investing in local partnerships, streamlining resources, prioritizing strong communication and outreach, and establishing explicit operating procedures. The majority of participants noted that challenges lessened over time.

CONCLUSIONS

Evaluating successes and lessons learned in CHW work is critical to maximize CHWs' abilities to address clients' health needs and promote health in underserved communities. This study provides important insights into how to successfully integrate CHWs into the public health workforce.

Educational and home-environment asthma interventions for children in urban, low-income, minority families

OBJECTIVE

This review examined the impact of environmental change and educational interventions targeting young children from minority groups living in urban environments and who were from low-income families.

DATA SOURCES

A scoping methodology was used to find research across six databases, including CINAHL, ERIC, PsycINFO, PubMed, MEDLINE, and EMBASE.

STUDY SELECTION

299 studies were identified. Duplicates were removed leaving 159 studies. After reviewing for inclusion and exclusion criteria, 23 manuscripts were identified for this study: 11 featured home-environment change interventions and 12 emphasized education of children.

RESULTS

Studies were reviewed to determine key interventions and outcomes for children. Both environmental interventions and educational programs had positive outcomes. Interventions did not always impact health outcomes, such as emergency department visits.

CONCLUSIONS

Results indicated many of the environmental change and education interventions improved asthma management and some symptoms. A multipronged approach may be a good method for targeting both education and change in the home and school environment to promote the well-being of young children in urban areas. New research with careful documentation of information about study participants, dose of intervention (i.e., number and duration of sessions, booster sessions) and specific intervention components also will provide guidance for future research.

Effectiveness of Evidence-Based Asthma Interventions

BACKGROUND AND OBJECTIVES

Researchers often struggle with the gap between efficacy and effectiveness in clinical research. To bridge this gap, the Community Healthcare for Asthma Management and Prevention of Symptoms (CHAMPS) study adapted an efficacious, randomized controlled trial that resulted in evidence-based asthma interventions in community health centers.

METHODS

Children (aged 5-12 years; N = 590) with moderate to severe asthma were enrolled from 3 intervention and 3 geographically/capacity-matched control sites in high-risk, low-income communities located in Arizona, Michigan, and Puerto Rico. The asthma intervention was tailored to the participant's allergen sensitivity and exposure, and it comprised 4 visits over the course of 1 year. Study visits were documented and monitored prospectively via electronic data capture. Asthma symptoms and health care utilization were evaluated at baseline, and at 6 and 12 months.

RESULTS

A total of 314 intervention children and 276 control children were enrolled in the study. Allergen sensitivity testing (96%) and home environmental assessments (89%) were performed on the majority of intervention children. Overall study activity completion (eg, intervention visits, clinical assessments) was 70%. Overall and individual site participant symptom days in the previous 4 weeks were significantly reduced compared with control findings (control, change of -2.28; intervention, change of -3.27; difference, -0.99; P < .001), and this result was consistent with changes found in the rigorous evidence-based interventions.

CONCLUSIONS

Evidence-based interventions can be successfully adapted into primary care settings that serve impoverished, high-risk populations, reducing the morbidity of asthma in these high-need populations.