标题：Impact of a Household Environmental Intervention Delivered by Lay Health Workers on Asthma Symptom Control in Urban, Disadvantaged Children With Asthma
摘要：Objectives. We examined whether a home-based educational and environmental intervention delivered by lay health educators would improve asthma symptom control in inner-city children with asthma. Methods. Children 2 to 16 years of age with diagnosed asthma and at least 1 asthma-related hospitalization or 2 emergency visits in the prior year were randomly assigned into 2 groups (immediate and delayed intervention) in a crossover study. Each group participated in the active phase (intervention) and the inactive phase. Outcomes included asthma symptoms, albuterol use, emergency department visits, hospitalizations, and trigger reduction. Results. A total of 264 primarily Black (94%) children were enrolled. The mean number of emergency visits decreased by 30% and inpatient visits decreased by 53% ( P < .001) after the intervention. Reductions were seen in pests, presence of carpets in bedrooms, and dust. Nighttime wheezing was significantly reduced after the intervention in both groups ( P < .001). Conclusions. Lay health educators effectively reduced asthma triggers and increased caregiver asthma knowledge, which resulted in reduced emergency department visits, hospitalizations, and asthma symptoms. The relationships formed between the caregivers and the lay health educators appeared to positively impact asthma outcomes in this disadvantaged population. Asthma prevalence rates and morbidity indices are historically high, having doubled from the 1980s to the 1990s. 1 With annual estimates of 12.3 million physician office visits and 1.8 million visits to emergency departments for asthma, the disease exerts a large cost and resource burden on the United States health care system. 2 Asthma places a huge burden on families regarding medical care, psychosocial stressors, and daily living. This burden is magnified in populations who are poor, African American, Hispanic, or disadvantaged. 3 The 2- to 3-fold higher rate of emergency department visits by African Americans and Hispanics reflects the disproportionate burden. 2 The causes of these disparities are many, including disparities in appropriate asthma care, environmental exposures, and other psychosocial issues. 3 Asthma management includes medical therapy as well as allergen avoidance. 4 The current national asthma guidelines recommend focus on symptom control as a function of appropriate asthma management. Symptoms include wheezing, coughing, and chest tightness in the day and night. Reduction of these symptoms is considered improved control, as is less use of quick-relief medicines. Environmental asthma allergen mitigation has been demonstrated to reduce inpatient hospitalizations and emergency department visits and to reduce some asthma symptoms. 4 The cost of the various strategies used to reduce exposure to these aeroallergens, however, are potentially prohibitive for disadvantaged populations. 5 The Community Asthma Prevention Program of The Children's Hospital of Philadelphia partnered with The Children's Services Incorporated and the University of Pennsylvania Institute of Environmental Health Sciences to design and implement an asthma environmental intervention to address these disparities in a minority inner-city community characterized by overcrowding, older dilapidated housing, and limited resources. The environmental justice issue raised was, how do we empower residents of this community to reduce the asthma burden in their children? In light of studies demonstrating the importance of asthma symptom control, the partners decided to implement and study a low-cost educational and environmental mitigation intervention as a potential solution for improving symptom control, thereby reducing inpatient and emergency department visits. Previous studies have shown that home environmental education along with mitigation efforts can reduce asthma symptoms. 6 – 8 For example, the National Cooperative Inner City Asthma Study (NCICAS), 9 a multisite randomized controlled study, included tailored environmental interventions and asthma counseling by a master's-prepared social worker. All participants received dust and cockroach mitigation, but other environmental interventions were based on the child's skin-testing results. The NCICAS outcomes showed that this intervention method led to reduced asthma symptoms. Given that the focus of our environmental justice intervention was on a similar inner-city population, our intervention targeted the common indoor triggers found in NCICAS–dust, cockroaches, rodents, pets, and tobacco smoke exposures—but tailored the interventions on the basis of general exposure to these triggers instead of on specific allergens found from skin tests. Our rationale for this more generalized approach was that atopic children with repeated exposures to indoor allergens can eventually develop asthma symptoms from exposure to the perennial allergens. 10 Additionally, because most disadvantaged urban children with asthma are managed by primary-care providers rather than specialists, we sought to look at a low-cost approach that would be more easily disseminated among these communities, thereby removing the social barriers that prevent many families from attending specialist visits. Another unique aspect of our study was the use of community health workers or lay health educators to implement the intervention rather than a master's-level trained professional. The use of lay health educators allowed families to be effectively taught and trained at a relatively lower cost by peers who lived in their communities and faced similar social barriers. Previously, we conducted a randomized controlled trial to study this approach in which we followed the participants for 1 year. We found that both control and intervention groups experienced improved outcomes, whereas the placebo group did not. 6 In the present study, we looked at the effectiveness of a 6-month-long intervention period to determine whether similar outcomes could be obtained. We hypothesized that empowering families with education and environmental supplies would lead to sustainable practices in the homes of children with asthma and would reduce asthma morbidity. We describe the impact of a low-cost environmental mitigation program on symptom control, use of short-acting β -agonists, and the number of asthma-related inpatient and emergency department visits in urban, disadvantaged children with asthma.
