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  • These efforts have generally comprised community health workers who assist family members in their homes with 1)asthma management and 2) modification of the environment of the house especially the child’s living space.
  • The assessments of these interventions have tended to illustrate that home environments can be modified and some have shown that children who have been targeted by these programs can experience reductions in symptoms and health care use.
  • However, in these evaluations, the effects of the home modification have not been tested separately from the education and behavioral change strategies also employed. Further, in some studies where home modification has been achieved and reductions in presence of allergens noted, no differences in the child’s health status have been observed.
  • These have focused on games and innovative ways for children to learn about asthma in a form that children are familiar with and like to use
  • The majority of these studies have assessed changes in children’s knowledge of asthma.
  • General knowledge about a disease has been shown in many studies not to correlate strongly with behavioral change. One or two studies have shown changes in symptoms or health care use but these have not involved large numbers of subjects. Further, important targets of change: children in asthma hot spots are the least likely to have access to a personal computer
  • Among community based programs, these are the interventions that have received the most attention in evaluation.
  • School based programs have shown positive results regarding the management of children’s asthma, improvement in school performance and reductions in symptoms.
  • These programs can be complicated to provide in school systems where resources are limited. There is one example where a program has been widely disseminated but despite promising outcomes, generally, this has not occurred. Although a number of asthma coalitions are working in schools, money for these coalitions is also an issue.
  • There are over 200 asthma coalitions in the U.S. alone. These have become a popular means of seeking community wide change regarding asthma morbidity. The premise is that these forms of community action can bring to the table individuals and organizations that don’t usually collaborate in solving health problems.
  • Coalitions in general and asthma coalitions in particular have predicated their work on the following logic: Ultimate outcomes in the form of reductions in morbidity and health care use will result from system and policy changes
  • As a result of this logic and of the methodological and financial difficulties associated with conducting population wide research to assess the desired ultimate outcome, evaluation of asthma coalitions and partnerships have been scant.
  • Descriptive data suggests number of coalitions have achieved significant change in the communities where they work. However, these forms of action are not generally viewed by health care institutions as central to their mission. The support for the work of coalitions has tended to come from foundations. Data illustrating the effect on individual patients of the work of coalitions are likely necessary if health care providers/insurers are to see coalitions as worthy of their investment. This is the case even though most providers/insurers state that they are very interested in the type of intermediary outcomes coalitions have been shown to produce.
  • Trends differ by the need and constituency viewed. -reduction in funds available for demonstration and evaluation of community approaches to controlling disease has led to reduction in assessments of social, behavioral and policy interventions. This means fewer innovations being generated and less understanding of the functioning and effectiveness of innovations that are attempted. -community health workers are increasingly viewed by public health oriented providers (journal commentaries, conference presentations) as a means to achieve asthma control but in most areas of the country, their work is not a reimbursable cost - there is increased discussion of schools as a means to reach children with asthma (journal supplements, commentaries, community opinion) yet there is rarely a sponsor in most communities who believes there might be direct financial reward for such sponsorship -there is greater interest in and evidence of community coalitions and partnerships around the country, perhaps a result of greater belief in them as a partial solution to the problem but also need to share resources. However there is little financial support available for them. -where community based interventions have been shown to be effective, generally they have not been continued or widely disseminated. As a result, the wheel continues to be reinvented in local communities around the country at considerable cost. -although many of the social, behavioral, policy influences on the health of children with asthma have been identified, effective clinical practices have been recommended, and promising interventions tested, there is a general public fatigue with asthma and failure to recognize the ongoing threat it poses to children’s health and well being.
  • NAEPP, CDC, the Merck Foundation and others have stated and in some cases supported the need to use proven models when intervening in asthma. The need to use proven models should become the mantra in health care systems and community organizations. Communications to influentials in the health care community from key agencies should include this idea as the standard of care. Further, a compendium of the available models should be produced and made widely available in all formats (hard copies, on line) to key players in the health care community. A significant investment by funders (perhaps even collectively) should be made in dissemination research, that is, development of methodologies for making widely available and supporting the initiation of programs, partnerships, policies that have been proven to have a positive effect on children’s asthma. Often this type of research is seen as soft and frilly. Given the state of health care in the US it should be seen as crucial. Reinvigoration by funders of their efforts to support intervention research that reaches across communities and trys to attenuate social and behavioral influences on asthma and asthma management. Applications are only as good as the science that undergirds them.
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    1. 1. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan
    2. 2. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan
    3. 3. In asthma, four types of community interventions have been examined <ul><li>Outreach from health care institutions </li></ul><ul><li>Home based computer programs </li></ul><ul><li>School based programs </li></ul><ul><li>Coalitions and partnerships </li></ul>
    4. 4. Outreach to patients’ homes by community health workers to: <ul><li>Provide self-management education </li></ul><ul><li>Assist with environmental modifications </li></ul>
    5. 5. Summary of Studies: Community health worker based randomized trials Fewer SX days for younger children only. Better quality of life for parents of younger children &quot;Wee Wheezers&quot; at home < 7 years old N=95 Brown et al, Journal of Pediatric Psychology , 2002 Reduced acute visits in active intervention; slight reduction in allergen presence; decrease in mite allergen Assistance with home prevention (3 Groups) N=104 Carter et al, Journal of Allergy & Clinical Immunology, 2001 Fewer sick days; less hospitalization; greatest effect for severe asthma Social workers individualized education for family N=1033 Evans et al, Journal of Pediatrics, September 1999 Improved quality of life; less urgent care High vs. low intensity environmental control & education N=274 Krieger et al, American Journal of Public Health, April 2005 Reduction in dust mite; improved functioning (most severe) Modification of Environment N=410 Williams et al, National Medical Association, February 2006 Outcome Intervention Sample Size Publication
    6. 6. Issues <ul><li>Effects of environment change not separated from education </li></ul><ul><li>Cost of environmental modifications </li></ul>
    7. 7. Computer Programs for Home Use <ul><li>Computer programs focus on games and problem solving </li></ul>
    8. 8. <ul><li>Summary of Studies: Computer programs at home randomized trials </li></ul>NS Asthma & Management CAI vs. Written N=137 Homer et al, Pediatrics , July 2000 Increased self-efficacy Self Management Education N=76 Shegog et al, Journal American Inform Association, January 2001 NS Asthma Game N=101 Hass et al, Journal of Pediatric Health Care, March 2003 Outcome Intervention Sample Size Publication
    9. 9. Issues <ul><li>Limited success </li></ul><ul><li>Majority of studies test knowledge </li></ul><ul><li>Small numbers </li></ul><ul><li>Overlooks children without computers </li></ul>
    10. 10. School Based Interventions <ul><li>Focus on child’s self-management </li></ul><ul><li>Conducted with and without school based health services </li></ul>
    11. 11. <ul><li>Summary of Studies: School based randomized trials </li></ul>Reduced SX in persistent group; better grades; fewer missed school days Comprehensive Management Education N=835 Clark et al, Chest , May 2004 Reduced missed school days and SX School Based Meds N=180 Halferman et al, Archives of Pediatric & Adolescent Medicine , May 2004 Reduced missed school days & unscheduled doctor visits; reduced SX Asthma Self-Management Education N=41 Tinkelman & Schwartz, Journal of Asthma, June 2004 Reduced hospital & ED visits; care costs reduced School Based Asthma Clinic N=273 Gus et al, Journal of Adolescent Health , October 2005 Improved quality of life and reduced absenteeism Peer Education re: Asthma Management N=272 Shah et al, BMJ, March 2001 Reduced SX; reduced ED visits; better grades Self Management N=239 Evans et al, Health Education Quarterly , Fall 1997 Outcomes Intervention Sample Size Publication
    12. 12. Issues <ul><li>Difficult in school systems with limited resources </li></ul><ul><li>Replication generally does not occur </li></ul><ul><li>Sponsorship not forthcoming </li></ul>
    13. 13. Coalitions and Partnerships <ul><li>200+ asthma coalitions in the United States </li></ul><ul><li>Focus on community-wide changes </li></ul><ul><li>Bring disparate but key groups together </li></ul>
    14. 14. Evaluation Logic <ul><li>Eventual improved health status results from: </li></ul><ul><ul><li>Health system-wide changes </li></ul></ul><ul><ul><li>Community-wide policies </li></ul></ul>
    15. 15. <ul><li>Summary of Studies: Community Coalitions & Partnerships </li></ul>• Community wide pt registries (2) • Care coordinators across hospitals & clinics (2) • Integration of CHW with Clinic Care (4) • Community wide education for clinicians (6) • Environment Control Policies (1) 7 Asthma Coalitions Across the United States Clark et al, Health Promotion Practice, April 2006 Reduced acute care rates among high level of participants Neighborhood Asthma Coalition Fisher et al, Pediatrics, December 2006 • Community education re: housing rights • Public education re: asthma • School environment assessments • Advocacy for air quality • Asthma action plans in schools community-wide 11 Coalitions Across California Kreger et al, Report of California Community Action to Fight Asthma Initiative, 2005 Outcomes Intervention Publication
    16. 16. Issues <ul><li>Lack of outcome of studies </li></ul><ul><li>Support has been from foundations </li></ul><ul><li>Population data not collected </li></ul>
    17. 17. In Summary <ul><li>Good models of interventions exist for: </li></ul><ul><ul><li>community outreach (CHW) </li></ul></ul><ul><ul><li>school based programs </li></ul></ul><ul><ul><li>coalitions and partnerships </li></ul></ul>
    18. 18. Trends <ul><li>Less examination of social, behavioral, policy interventions </li></ul><ul><li>Work of community health workers not being reimbursed </li></ul><ul><li>No continuing sponsorship for school programs or coalitions </li></ul><ul><li>Proven programs not disseminated </li></ul><ul><ul><li>Reinvention of the wheel </li></ul></ul><ul><li>Asthma fallen off the radar </li></ul>
    19. 19. Ideas to Enhance Application <ul><li>Initiate a targeted campaign to reach health system influentials: ongoing messages and encouragement to support use of proven programs </li></ul><ul><li>Provide a compendium of proven programs and “how to’s” as part of the campaign </li></ul><ul><li>Funders initiate research into effective channels for dissemination of programs </li></ul><ul><li>Reinvigorate support for community intervention research including evaluation methodology </li></ul>
    20. 20. Effectiveness of Community Based Interventions for Children with Asthma Noreen M. Clark, PhD Myron E. Wegman Distinguished University Professor Director, Center for Managing Chronic Disease University of Michigan