An Evaluation of a State-Funded Healthy Homes Intervention on Asthma Outcomes in Adults and Children

Abstract

Context:
Reducing exposure to environmental triggers is a critical part of asthma management.

Objective:
To evaluate the impact of a healthy homes intervention on asthma outcomes and assess the impact of different targeting strategies.

Setting:
The New York State (NYS) Healthy Neighborhoods Program (HNP) operates in select communities with a higher burden of housing-related illness and associated risk factors.

Participants:
Residents with asthma were recruited through 3 mechanisms: door-to-door canvassing (CANVASSED), 752 residents in 457 dwellings; referrals from community partners (REFERRED), 573 residents in 307 dwellings; referrals of Medicaid enrollees with poorly controlled asthma (TARGETED), 140 residents in 140 dwellings.

Intervention:
The NYS HNP provides visual assessments and low-cost interventions to identify and address asthma triggers and trigger-promoting conditions in the home environment. Conditions are reassessed during a revisit conducted 3 to 6 months after the initial visit.

Main outcome measure(s):
The analysis compares improvements across the 3 groups for measures of asthma self-management, health care access, morbidity, and environmental conditions. An asthma trigger score characterizing the extent of multiple triggers in a dwelling was also calculated.

Results:
Among 1465 adults and children, there were significant improvements in environmental conditions and self-reported self-management, health care access, and asthma morbidity outcomes for each group. The improvement was greatest in the TARGETED group for most outcomes, but selected measures of self-management and health care access were greater in the other groups. The mean improvement was significantly greater in the TARGETED group.

Conclusion:
Targeting the intervention to people with poorly controlled asthma maximizes improvements in trigger avoidance and asthma morbidity; however, other recruitment strategies are effective for impacting endpoints related to health care access and self-management. This evaluation demonstrates that a low-intensity home-based environmental intervention is effective as well as practical and feasible. Health care payers, state and local health departments, and others should consider investing in these home-based services as part of a comprehensive asthma care package.

Full text

Research Article
An Evaluation of a State-Funded Healthy Homes
Intervention on Asthma Outcomes in Adults
and Children
Amanda L. Reddy, MS; Marta Gomez, MS; Sherry L. Dixon, PhD
ABSTRACT
Context: Reducing exposure to environmental triggers is a critical part of asthma management.
Objective: To evaluate the impact of a healthy homes intervention on asthma outcomes and assess the impact of different
targeting strategies.
Setting: The New York State (NYS) Healthy Neighborhoods Program (HNP) operates in select communities with a higher
burden of housing-related illness and associated risk factors.
Participants: Residents with asthma were recruited through 3 mechanisms: door-to-door canvassing (CANVASSED), 752
residents in 457 dwellings; referrals from community partners (REFERRED), 573 residents in 307 dwellings; referrals of
Medicaid enrollees with poorly controlled asthma (TARGETED), 140 residents in 140 dwellings.
Intervention: The NYS HNP provides visual assessments and low-cost interventions to identify and address asthma triggers
and trigger-promoting conditions in the home environment. Conditions are reassessed during a revisit conducted 3 to
6 months after the initial visit.
Main Outcome Measure(s): The analysis compares improvements across the 3 groups for measures of asthma self-
management, health care access, morbidity, and environmental conditions. An asthma trigger score characterizing the
extent of multiple triggers in a dwelling was also calculated.
Results: Among 1465 adults and children, there were signicant improvements in environmental conditions and self-
reported self-management, health care access, and asthma morbidity outcomes for each group. The improvement was
greatest in the TARGETED group for most outcomes, but selected measures of self-management and health care access
were greater in the other groups. The mean improvement was signicantly greater in the TARGETED group.
Conclusion: Targeting the intervention to people with poorly controlled asthma maximizes improvements in trigger avoid-
ance and asthma morbidity; however, other recruitment strategies are effective for impacting endpoints related to health
care access and self-management. This evaluation demonstrates that a low-intensity home-based environmental interven-
tion is effective as well as practical and feasible. Health care payers, state and local health departments, and others should
consider investing in these home-based services as part of a comprehensive asthma care package.
KEY WORDS: asthma intervention, asthma outcomes evaluation, healthy homes, home environments, housing
People with poorly controlled asthma often
live in environments that exacerbate their
symptoms and minimize their ability to gain
control.1-5 Control of environmental factors is a key
component of asthma management, but education
Author Afliations: National Center for Healthy Housing, Columbia,
Maryland (Ms Reddy and Dr Dixon); and New York State Department of
Health, Albany, New York (Ms Gomez).
The authors thank the staff and participants of the New York State (NYS)
Healthy Neighborhoods Program and, in particular, Kenneth Boxley, Philip
DiMura, Joan Bobier, Thomas Carroll, and Michael Cambridge, and the many
residents who welcomed the program into their homes. The authors
acknowledge the NYS Asthma Control Program, the NYS Ofce of Health
Insurance Programs, the Erie County Department of Health, and the regional
Medicaid Managed Care Plans that participated in the Healthy Home
Environments for New Yorkers with Asthma (HHENYA) pilot initiative in
about asthma triggers is often not a routine part of
clinical asthma care. Evidence-based strategies exist,
such as home-based environmental interventions, but
are underutilized. The effectiveness of home-based
environmental interventions in reducing asthma
Buffalo, New York. The authors are also grateful to David Jacobs and
Jonathan Wilson for providing feedback on the manuscript.
The authors declare no conicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (http:// www.JPHMP.com).
Correspondence: Amanda L. Reddy, MS, BA, National Center for Healthy
Housing, 10320 Little Patuxent Pkwy, Ste 500, Columbia, Maryland 21044
(areddy@nchh.org).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/PHH.0000000000000530
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
March/April 2017 • Volume 23, Number 2 www.JPHMP.com 219

220 Reddy, et al • 23(2), 219–228 An Evaluation of a Healthy Homes Program for Residents With Asthma
morbidity is now well-established.6-32 This approach
has been effective at reducing the presence of common
asthma triggers and conditions that promote triggers
in the home and also for improving health outcomes.
Multiple studies have reported signicant reductions
following completion of a home visiting program in
emergency department (ED) visits, hospitalizations,
days with worsening asthma, days of school or work
missed because of asthma, improvements in appro-
priate use of medications, use of asthma action plans,
knowledge of personal triggers, and how to reduce
exposures to triggers. Projected costs and savings
vary according to program design and intensity, but
a Community Guide review concluded that home-
based, multitrigger, multicomponent interventions are
a good investment, with cost-benet ratios ranging
from a return of $5.30 to $14.00 for every dollar
invested.11
However, as health care payers consider opportu-
nities to translate this evidence into policy (eg, Med-
icaid coverage), several important questions remain.
For example, most of the evidence has emerged both
from studies conducted in urban settings and from
studies focused on children with asthma. As a re-
sult, the effectiveness of home visits for rural popu-
lations and adults with asthma has not been as well
characterized. Additional research gaps include the
impact of targeting services to residents with poorly
controlled asthma, stafng, number of visits, and re-
mediation intensity. This article addresses several of
these gaps by describing the impact of a state-funded,
home-based, environmental asthma intervention for
both pediatric and adult populations across a variety
of geographic settings. It also describes the differen-
tial impact of 3 recruitment methods on environmen-
tal, self-management, health care access and asthma
morbidity outcomes. Finally, the article contributes to
the evidence base about the effectiveness of nonclini-
cal staff in providing a low-intensity intervention and
characterizes the extent of asthma triggers within a
single dwelling by calculating an asthma trigger score.
Methods
The New York State (NYS) Healthy Neighborhoods
Program (HNP) provides in-home assessments and in-
terventions to reduce residential health and safety haz-
ards in selected communities throughout NYS. Since
2006, the HNP has been funded continuously from
the state’s general funds. We describe the program in
detail in a separate article.33 The HNP is best clas-
sied as a minor to moderate intervention that uses
a variety of lay staff (eg, sanitarians, health educa-
tors) to provide services.34 In a separate article, we
report that the HNP provides a favorable return on
investment, with an estimated benet to program cost
ratio of 2.03 and a net benet of $311 per resident
with asthma.35
Program description
During the evaluation time frame (2007-2011), 13
counties were funded to implement the program. Each
county selects high-risk areas to target based on zip
codes in urban areas, towns, or regions, and within
the target areas, the programs visit homes in se-
lected neighborhoods or blocks with the greatest need
(eg, older housing). Homes and residents are reached
through a combination of door-to-door canvassing
and referrals from other programs, local organiza-
tions, or health care providers. The program addresses
6 potential categories of health and safety hazards,
including the presence of common asthma triggers.
On the basis of the assessment, residents are provided
with education, referrals to services, or low-cost prod-
ucts to address identied problems. Once inside the
home, conditions are assessed and interventions are
provided as needed. Three to 6 months after the ini-
tial visit, the counties are expected to conduct revisits
for roughly a quarter of all homes, prioritizing those
with the most serious conditions and/or with residents
with asthma. During the revisit, the conditions are
reassessed and any new or ongoing problems are
addressed.
The HNP data are collected using a 2-part stan-
dardized form (see documents, Supplemental Digital
Content 1, available at: http://links.lww.com/JPHMP/
A290). The dwelling form includes demographic in-
formation about the primary respondent, character-
istics of the dwelling, enumeration of the residents,
physical conditions of the dwelling, and interventions
provided. The asthma form is completed for each per-
son with asthma and includes information about the
presence of asthma triggers, asthma symptoms and
morbidity, and self-management. No personal identi-
ers are collected. Completed forms are faxed to NYS
Department of Health (DOH), scanned, and extracted
data are saved to a database. Data elds are automat-
ically checked for completeness and valid values, and
errors are manually veried and corrected.
Analysis groups
We classied residents as having “active asthma” if
they used a quick-relief asthma medicine in the past
week, had a current prescription for a controller med-
ication, had an asthma attack in the past 3 months,
and/or 1 or more medical encounters in the past
12 months for an asthma attack or worsening
symptoms (an ED or urgent care visit, health care
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March/April 2017 • Volume 23, Number 2 www.JPHMP.com 221
professional visit, or hospital stay).36 To assess the
impact of targeting the intervention to people with
poorly controlled asthma, we evaluated outcomes for
3 groups of residents with active asthma, recruited
through different methods:
TARGETED: Residents in this group had poorly
controlled asthma, were enrollees of Medicaid
Managed Care Plans, and lived in one of 15
high-risk urban zip codes in one of the funded
counties. As part of a special initiative in this
county, managed care plans identied enrollees
with poorly controlled asthma on the basis of
an ED visit or hospitalization for asthma within
the previous 6 months or medication history in-
dicating poor control (eg, no evidence of lled
prescription for controller medication in past 6
months and 3 or more lled prescriptions for
quick-relief medications during the same time
period).
REFERRED: Residents in this group were referred
to the HNP from other programs, local organi-
zations, or health care providers (but not neces-
sarily on the basis of an asthma diagnosis) and
had a self-reported diagnosis of active asthma.
CANVASSED: Participants in this group were iden-
tied through door-to-door canvassing in high-
risk areas and had a self-reported diagnosis of
active asthma. Local county health departments
dene high-risk areas using census and surveil-
lance data to identify areas with poor housing
quality and high rates of housing-related illness
and injury.
To make the groups more comparable, data from 2
rural counties were excluded from the analysis.
The institutional review board of NYS DOH
granted exempt status to both the program evaluation
of the HNP and the targeting initiative on the basis of
not being research.
Analysis
Data were collected between October 1, 2007, and
June 30, 2011. This analysis focuses on the asthma
component of the intervention. Each environmental
condition and asthma self-management strategy re-
ported at the initial visit is coded present, absent, or
unknown (ie, not assessed or not applicable). At the
revisit, each is coded present, improved, absent, or un-
known. The presence of an environmental condition
is “bad”; the presence of an asthma self-management
strategy is “good.”Use of quick-relief medication and
morbidity outcomes are measured as the number of
occurrences within a specied time frame.36
For dwellings with a revisit, we present the per-
centage with the environmental condition at the ini-
tial visit and the change (percent improved) at the re-
visit, along with the exact binomial 95% condence
interval (CI) with continuity correction for the ob-
served change. To assess improvement, we looked
at dwellings where the condition was present at the
initial visit and calculated the percentage of these
dwellings where the condition was improved (ie, ab-
sent or still present but improved) at the revisit.
We used McNemar’s test to determine whether the
percentage with a hazard changed signicantly be-
tween visits and examined the overlap in 95% CIs for
between-group comparisons. Statistical signicance
was dened as P<.05. All analyses were conducted
with SAS (version 9.4; SAS Institute, Inc, Cary, North
Carolina).
We analyzed 3 asthma outcomes: days with wors-
ening asthma or attacks; days missed of school, day
care, or work due to asthma; days missed of school,
day care, or work by another family member. We
present the mean number for children and adults sep-
arately by the recruitment method at the initial visit,
revisit, and the change (initial visit −revisit) and its
95% CI.
The companion article by Reddy et al33 describes
the process used to select conditions for inclusion in
the home hazard score; the same method was used
to develop an asthma trigger score. Fourteen individ-
ual conditions were identied for possible inclusion
in the score.33 The nal score includes 10 elements
(6 individual conditions and 4 combined conditions)
that were weighted equally. Scores were calculated for
dwellings, not persons. One of the selected conditions,
sleeping in the same room as a pet, was reported at the
person level but analyzed at the dwelling level where
the trigger is present if any resident with asthma re-
ported sleeping with a pet with fur or feathers.
For a dwelling to be included in the analysis, we re-
quired nonmissing data for at least 8 of the 10 haz-
ards for each visit. If a hazard was missing at the
revisit but reported at the initial visit, the value for
the hazard was assigned the conditional prevalence
of that hazard at the revisit given the value (present
or absent) at the initial visit. If data were missing for
a hazard at both visits (if at least 8 other hazards
were nonmissing), the revisit value was assigned the
revisit prevalence of the hazard among the nonmissing
observations.
For each of the 3 groups, we present the mean
asthma trigger scores at the initial visit, revisit, and
change from the initial visit to the revisit. We used an
overall analysis of variance (ANOVA) F-test for the
hypothesis that at least 2 of the 3 groups have dif-
ferent means. For P<.05, we present Pvalues from
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222 Reddy, et al • 23(2), 219–228 An Evaluation of a Healthy Homes Program for Residents With Asthma
the ANOVA model-based ttest that the least squares
means are not equal for each pair of the groups.
Results
Table 1 presents the characteristics of the revisited
dwellings and residents by recruitment group. During
the evaluation period, 1465 residents with asthma in
904 dwellings completed both an initial visit and a
revisit. On the basis of information provided by the
primary respondents, a greater proportion of partic-
ipants in the TARGETED group compared with the
other groups were nonwhite (84% vs ∼50%, respec-
tively) and Hispanic/Latino (30% vs ∼15%, respec-
tively) and received public assistance (98% vs 60%-
77%, respectively). Roughly half of the participants
in each group were adults, and 60% to 70% of adults
and children were female.
We examined the prevalence of triggers and trigger-
promoting conditions at the initial visit and im-
provement following the intervention (see docu-
ments, Supplemental Digital Content 2, available at:
http://links.lww.com/JPHMP/A291). There were no-
table differences in the prevalence of triggers among
the groups, especially between the TARGETED and
CANVASSED groups. The prevalence of mold and
dust accumulation/ineffective housecleaning in the
TARGETTED group was 40% and 31%, respectively
(followed closely by the REFERRED group), but 10%
and 18%, respectively, in the CANVASSED group.
In contrast, the prevalence of smoking in the home
and mice in the CANVASSED group was 43% and
20%, respectively, compared with 26% and 6%, re-
spectively, in the TARGETED group. There were some
similarities and differences in the triggers that showed
signicant improvement (ie, a reduction in the pres-
ence of a trigger in homes where the trigger was
present at the initial visit). In the TARGETED group,
there was a modest but signicant (11%) reduction in
smoking but was not signicant in the other 2 groups.
There was a signicant reduction of 40% to 60% in
the presence of cockroaches and mold in all groups.
Rodents were reduced signicantly in all 3 groups, but
the magnitude ranged from 100% in the TARGETED
group, 61% in the REFERRED group, and 45% in the
CANVASSED group.
The mean asthma trigger score (ie, mean number of
asthma triggers per home) at the initial visit was be-
tween 1.6 and 1.8 for all groups and not signicantly
different (Table 2). At the revisit, the mean scores
were signicantly different (P<.001) for 2 pairs:
TARGETED versus REFERRED and TARGETED
versus CANVASSED. The mean scores decreased sig-
nicantly in all 3 groups (TARGETED, 0.8; RE-
FERRED, 0.5; and CANVASSED, 0.4) and the same 2
pairs were signicantly different: TARGETED versus
REFERRED and TARGETED versus CANVASSED.
Table 3 presents the prevalence of self-reported
asthma control measures and health care access end-
points at the initial visit and the change following
the intervention. In the TARGETED group, 19% of
individuals knew their personal triggers, 6% knew
how to avoid their triggers compared with about 70%
in the other 2 groups, and 21% reported that their
TA B L E 1
Characteristics of Dwellings (N =904) and Residents (N =1 465), by Recruitment Group
Characteristic
TARGETED
(140 Dwellings,
140 Residents)
REFERRED
(307 Dwellings,
573 Residents)
CANVASSED
(457 Dwellings,
752 Residents)
Visit interval (mean no. of days) 91 115 130
Dwelling
Multiunit building 68% 63% 54%
Built pre-1978 (pre-1950) 94% (78%) 96% (75%) 97% (76%)
Primary respondent (1 per dwelling)
Renter 86% 80% 73%
Nonwhite 84% 53% 52%
Hispanic/Latino 30% 16% 15%
Completed high school or equivalent 89% 79% 75%
Receives public assistance 98% 77% 60%
Receives rental assistance/Section 8 10% 32% 35%
Residents (1 or more per dwelling)
Adults (children) 52% (48%) 51% (49%) 57% (43%)
Male (female) 30% (70%) 37% (63%) 39% (61%)
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March/April 2017 • Volume 23, Number 2 www.JPHMP.com 223
TA B L E 2
Asthma Trigger Scores at Initial Visit and Revisit and Change Between Visits, by Recruitment Group
Asthma Trigger
Scores, Mean (95% CI) P
Visit(s)
TARGETED
(113
Dwellings)
REFERRED
(283
Dwellings)
CANVASSED
(363
Dwellings)
Group
Differences
Overalla
TARGETED vs
REFERREDb
TARGETED vs
CANVASSEDb
REFERRED vs
CANVASSEDb
Initial visit 1.6 (1.3-1.8) 1.7 (1.5-1.9) 1.8 (1.7-2.0) .20 … … …
Revisit 0.7 (0.6-0.9) 1.2 (1.1-1.4) 1.4 (1.3-1.6) <.001 <.001 <.001 .05
Change from initial visit
to revisit
0.8 (0.7-1.0) 0.5 (0.3-0.6) 0.4 (0.3-0.5) <.001 .002 <.001 .33
Abbreviations: ANOVA, analysis of variance; CI, condence interval.
aOverall ANOVA Ftest that at least 2 of the 3 groups have different means.
bANOVA model-based ttest that least squares means are not equal for paired groups. If the Ftest is not signicant, then the paired Pvalues are not presented.
asthma was well controlled compared with 74% and
88% in the REFERRED and CANVASSED groups,
respectively. A small percentage of individuals in all
3 groups used a peak ow meter (10%-17%) or had
a written asthma action plan (10% in the TARGET-
TED group, 14% in the REFERRED group, and 19%
in the CANVASSED group). Among the endpoints
with the lowest percentage of participants who did
not know or used strategies, the greatest signicant
improvements were reported for participants in the
TARGETED group for knowing their personal trig-
gers (100%), knowing how to avoid triggers (100%),
and using the peak ow meter (85%). In addition, in
this group, all of the individuals who were not taking
their controller medication every day were taking it
every day at the revisit.
Self-reported short-term asthma morbidity out-
comes are summarized in Table 4. At the initial visit,
children in the TARGETED group reported an aver-
age of 6.2 days with worsening asthma or attacks in
the previous 3 months, 5.8 missed days of school or
day care in the 3 months leading up to the initial visit,
and 1.0 missed days of work by another family mem-
ber because of that child’s asthma. The other groups
had lower means than the TARGETED group. After
the intervention, children in the TARGETED group
had signicantly lower means: 2.8 missed days with
worsening asthma, 2.0 missed days of school or day
care, and 0.4 missed days of work by another family
member. Adults in the TARGETED group reported an
average of 7.1 missed days with worsening asthma at
the initial visit, which decreased to 4.3 missed days af-
ter the intervention. The mean number of missed days
of school or work and missed days of work by another
family member were negligible in all 3 groups.
As noted in the “Methods” section, data from 2 ru-
ral counties were excluded from the results presented
to facilitate comparison between the urban-only
TARGETED group and the other groups. Among data
not shown, when the rural counties were included in
the CANVASSED and REFERRED groups, the mag-
nitude of the effects differed slightly but the statistical
signicance of the comparisons did not change.
Discussion
Within a short follow-up period, there were improve-
ments in health and environmental outcomes for all
3 groups. Targeting the intervention to people with
poorly controlled asthma appears to result in a greater
magnitude of improvement for outcomes related to
trigger avoidance and asthma morbidity, but other re-
cruitment strategies may be more effective for impact-
ing health care access and self-management. These
ndings are important, but not surprising. People who
are sicker at the beginning of an intervention (ie, have
more poorly controlled asthma) have a greater ca-
pacity to benet and, as a result of their illness, may
also be better connected to health care systems that
provide and reinforce basic self-management strate-
gies. In addition, people in the targeted group were
referred specically for the assessment of possible trig-
gers in the home and thus may have been motivated
to implement trigger-avoidance strategies. Conversely,
door-to-door canvassing may be an important way to
identify residents who are not yet connected to the
health care system and equip them to maintain con-
trol of their asthma.
Generally speaking, our ndings are consistent with
previous studies in demonstrating reductions in the
presence of asthma triggers, improvements in self-
management outcomes, and reductions in asthma
morbidity, even with a relatively low-intensity inter-
vention provided by nonclinical staff.6-32 They also
conrm that targeting services to patients with more
poorly controlled asthma has the potential to increase
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224 Reddy, et al • 23(2), 219–228 An Evaluation of a Healthy Homes Program for Residents With Asthma
TA B L E 3
Prevalence of and Improvement in Self-management Strategies and Health Care Access Outcomes, by Recruitment Group
TARGETED (140 Residents With Asthma) REFERRED (573 Residents With Asthma)
CANVASSED (752 Residents With
Asthma)
Revisit Revisit Revisit
Outcomes
Initial
Visit
Percent
Improveda95% CI
Initial
Visit
Percent
Improveda95% CI
Initial
Visit
Percent
Improveda95% CI
Self-reported knowledge
Told smoking is bad 43.6% 100 99.4-100 79.1% 11.2 6-16.4 94.2% 42.2 26.7-57.8
Knows early warning signs 100% 0 0-0 96.5% 81.5 65.0-98.0 94.5% 63.6 48.3-79.0
Knows what to do for worsening asthma 100% 0 0-0 97.6% 79.0 58.0-99.9 96.1% 77.4 61.1-94.0
Knows personal triggers 19.3% 100 99.6-100 70.7% 89.3 85.1-93.6 88.2% 38.7 28.3-49.2
Knows how to avoid triggers 6.4% 100 99.6-100 68.7% 88.0 83.7-92.3 86.2% 41.3 31.6-51.0
Self-reported asthma control measures
Feels asthma is well controlled 20.7% 63.1 53.6-72.5 73.5% 65.7 58.9-72.5 88.1% 38.7 28.3-49.2
Uses a peak ow meter 17.1% 84.5 77.5-91.5 13.2% 24.4 21.0-27.7 9.5% 6.7 4.7-8.6
Has a written asthma action plan 10.0% 2.4 0-5.4 13.9% 7.8 5.7-10.0 19.3% 9.0 6.6-11.3
Health care access and medication use
Has PCP 100% 0 0-0 96.4% 57.1 37.0-77.3 97.3% 50.0 26.8-73.2
Has health insurance 100% 0 0-0 96.0% 38.7 20.0-57.5 96.0% 40.6 22.1-59.2
Has QR medication 98.6% 0 0-0 92.2% 31.7 19.1-44.3 90.9% 16.7 7.4-26.0
Took QR medications twice per week 17.5% 21.2 13.3-29.2 55.6% 30.0 24.7-35.3 65.1% 25.3 19.7-31.0
Has controller medication 72.7% 23.7 8.8-38.5 60.6% 9.5 6.1-13.0 61.9% 12.2 8.4-16.1
Took it every day 85.0% 100 96.7-100 80.2% 40.2 29.4-51.1 78.2% 21.4 12.8-30.1
Abbreviations: PCP, primary care provider; QR, quick-relief.
aBold values are signicant at P<.05.
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March/April 2017 • Volume 23, Number 2 www.JPHMP.com 225
TA B L E 4
Short-term Asthma Morbidity Outcomes, by Recruitment Group and Age (Children and Adults)
TARGETED (n =140 Residents With
Asthma; 67 Children, 73 Adults)
REFERRED (n =573 Residents With
Asthma; 281 Children, 292 Adults)
CANVASSED (n =752 Residents With
Asthma; 323 Children, 429 Adults)
Mean Number Mean Number Mean Number
Age Group and Asthma Morbidity Outcome
Initial
Visit Revisit
Mean
Change
(95% CI)
Initial
Visit Revisit
Mean
Change
(95% CI)
Initial
Visit Revisit
Mean
Change
(95% CI)
Children with asthma
Number of days in past 3 mo
Experienced worsening asthma or asthma
attacks
6.2 2.8 3.4 (2.1-4.7) 2.6 2.2 1.2 (0.4-2.0) 0.9 0.6 0.3 (0.1-0.6)
Missed school, day care, or work due to asthma 5.8 2.0 3.9 (2.5-5.2) 1.8 0.7 1.1 (0.7-1.5) 0.6 0.3 0.3 (0.1-0.5)
Another family member missed school, day
care, or work due to asthma
1.0 0.4 0.6 (0.2-1.1) 0.3 1.9 -1.6 (−1.7 to −1.5) 0.3 0.2 0.1 (0.0-0.3)
Adults with asthma
Number of days in past 3 mo
Experienced worsening asthma or asthma
attacks
7.1 4.3 2.8 (2.0-3.7) 4.0 2.8 1.2 (0.4-2.0) 1.3 0.9 0.3 (−0.01 to 0.7)
Missed school, day care, or work due to asthma 0.4 0.2 0.2 (−0.1 to 0.6) 0.3 0.1 0.2 (0.0-0.3) 0.4 0.3 0.1 (−0.2 to 0.5)
Another family member missed school, day
care, or work due to asthma
0 0 0 (0-0) 0 0 0 (0.0-0.1) 0.1 0 0.1 (−0.1 to 0.3)
Abbreviation: CI, condence interval.
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226 Reddy, et al • 23(2), 219–228 An Evaluation of a Healthy Homes Program for Residents With Asthma
the observed impact of the intervention and that
homes generally have more than 1 asthma trigger or
trigger-promoting condition. However, differences in
program design among published studies complicate
direct comparisons. For instance, differences in geog-
raphy and population can impact the observed preva-
lence of environmental conditions, self-management
strategies, and access to health care. Likewise, differ-
ences in stafng and intervention intensity are likely to
impact the magnitude of improvement observed (eg,
lower-intensity interventions may have more modest
improvements in environmental outcomes, and inter-
ventions that do not use clinical staff to reinforce self-
management messages during the visit may show less
improvement there).
This article adds new information about the impact
of the intervention on adults. While programs focused
on pediatric asthma are much more prevalent, strate-
gies that reduce asthma morbidity for adults are of po-
tentially great importance to health care payers. Not
only are there more adults with asthma but in NYS,
where this program operates, adults also incur higher
asthma-related medical costs, thereby increasing the
potential for signicant health care savings.37
Although the information regarding the impact on
children is less novel, the impact on missed school
days is notable. A reduction of up to 3.9 days per
3-month period could mean a reduction of up to 11.7
fewer days of missed school in a 9-month school year
period. As asthma is a leading cause of school absen-
teeism, with associated consequences for educational
outcomes and school budgets, this suggests that part-
nerships between the education and health care sec-
tors to provide services to children with poorly con-
trolled asthma may be of mutual benet.
Finally, this article not only reinforces previous nd-
ings that improvements can be maximized by target-
ing the intervention to people with poorly controlled
asthma but also highlights the role for other recruit-
ment strategies.
Limitations
While this article adds to the evidence base about
the impact of low-intensity, home-based, environmen-
tal asthma interventions, there are also a number of
limitations. For instance, the short follow-up period
prevents an examination of longer-term sustainability
of observed improvements. On the contrary, the low-
intensity approach and the short follow-up period are
likely more relevant for government agencies design-
ing approaches to reach a large number of residents
with asthma.
The lack of a control group, and corresponding
inability to attribute observed improvements to the
Implications for Policy & Practice
■Although control of environmental factors is a critical com-
ponent of guideline-based asthma care, many health care
providers and systems struggle to address this aspect of
asthma management in the traditional context of the clini-
cal setting.
■This article reinforces previous ndings that home-based en-
vironmental interventions are an effective means for reduc-
ing exposure to triggers in the home environment and reduc-
ing asthma morbidity among children and adults.
■By highlighting the impact across many different communi-
ties using a low-intensity approach, and taken with ndings
from the companion article about the relatively low cost and
potential for return on investment, it also contributes to the
evidence base that these solutions are practical and feasible,
in addition to being effective.
■Health care payers, state and local departments of public
health, and other organizations that provide services to com-
munities with high rates of asthma morbidity should consider
investing in these home-based services as part of a compre-
hensive asthma care package.
intervention alone, is another limitation, but the inclu-
sion of comparison groups illustrated the expected in-
crease in improvements for patients with more poorly
controlled asthma and provided critical insights about
the potential for other recruitment strategies to affect
health care access and self-management endpoints.
Another challenge in addressing environmental
asthma triggers is that asthma is a complex and highly
individualized disease. While information about pa-
tient sensitivities would be useful in further customiz-
ing the intervention, an insistence on allergen test-
ing would increase costs and could pose barriers
for patients who lack access to specialist care or
are not motivated to undergo testing. Furthermore,
some triggers are irritants, not allergens. There may
be a benet of allergen testing as a prerequisite for
services, but this evaluation suggests that it is not
required to achieve signicant reductions in health
outcomes.
Sources of potential bias for this analysis include
which homes allow access, which are targeted for re-
visit, recall bias (reporting of exposure to triggers fol-
lowing an ED visit), social desirability bias (reluctance
to report tobacco use), and reporting bias by the out-
reach worker evaluating his or her own work at the
revisit. The impact of social desirability bias is mit-
igated somewhat by a reliance on visual assessment
over self-report, and the impact of other potential bias
is unknown.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

March/April 2017 • Volume 23, Number 2 www.JPHMP.com 227
Conclusion
A low-intensity, home-based, environmental asthma
intervention using nonclinical staff can decrease the
presence of asthma triggers and improve asthma self-
management and morbidity outcomes for both adults
and children. Targeting the intervention to people
with poorly controlled asthma may result in a greater
magnitude of improvement for outcomes related to
trigger avoidance and short-term asthma morbidity,
but other recruitment strategies may be more effec-
tive for improving health care access and selected as-
pects of self-management. This evaluation, and others
before it, offers a practical and cost-effective solution
for increasing access to evidence-based asthma care
by offering home-based environmental interventions
as a complement to routine clinical care for patients
with poorly controlled asthma.
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