A community-based participatory research study of multifaceted in-home environmental interventions for pediatric asthmatics in public housing

Harvard School of Public Health, Boston, MA 02215, USA.
Social Science & Medicine (Impact Factor: 2.89). 11/2006; 63(8):2191-203. DOI: 10.1016/j.socscimed.2006.05.006
Source: PubMed


Pest infestation is a major problem in urban, low-income housing and may contribute to elevated asthma prevalence and exacerbation rates in such communities. However, there is poor understanding of the effectiveness of integrated pest management (IPM) efforts in controlling pediatric asthma, or of the interactions among various interventions and risk factors in these settings. As part of the Boston-based Healthy Public Housing Initiative, we conducted a longitudinal, single-cohort community-based participatory research intervention study. Fifty asthmatic children aged 4-17 from three public housing developments in Boston, Massachusetts, USA successfully completed interventions and detailed environmental, medical, social, and health outcome data collection. Interventions primarily consisted of IPM and related cleaning and educational efforts, but also included limited case management and support from trained community health advocates. In pre-post analyses, we found significant reductions in a 2-week recall respiratory symptom score (from 2.6 to 1.5 on an 8-point scale, p = 0.0002) and in the frequency of wheeze/cough, slowing down or stopping play, and waking at night. Longitudinal analyses of asthma-related quality of life similarly document significant improvements, with a suggestion of some improvements prior to environmental interventions with an increased rate of improvement subsequent to pest management activities. Analyses of potential explanatory factors demonstrated significant between-development differences in symptom improvements and suggested some potential contributions of allergen reductions, increased peak flow meter usage, and improved social support, but not medication changes. In spite of limitations with pre-post comparisons, our results are consistent with aggressive pest management and other allergen reduction efforts having a positive impact on clinical health outcomes associated with asthma. Our findings reinforce the multifactorial nature of urban asthma and suggest a need for further study of the relative contributions of and possible synergies between environmental and social factors in asthma intervention programs.

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    • "However, asthma trigger reduction behavior among caregivers varied among studies. In a community-based, participatory research (CBPR) environmental intervention study conducted among children (4–17 years) with asthma (N = 50) in public housing, Levy et al identified significant reductions in respiratory symptoms after implementing integrated pest management (IPM), cleaning, and educational efforts.37 "
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    ABSTRACT: OBJECTIVE Asthma is the most common chronic childhood condition affecting 6.3 million (US) children aged less than 18 years. Home-based, multi-component, environmental intervention studies among children with asthma have demonstrated to be effective in reducing asthma symptoms. In this study, a local hospital and university developed an environmental intervention research pilot project, Eastern Carolina Asthma Prevention Program (ECAPP), to evaluate self-reported asthma symptoms, breathing measurements, and number of asthma-related emergency department (ED) visits among low-income, minority children with asthma living in rural, eastern North Carolina. Our goal was to develop a conceptual model and demonstrate any asthma respiratory improvements in children associated with our home-based, environmental intervention. METHODS This project used a single cohort, intervention design approach to compare self-reported asthma-related symptoms, breathing tests, and ED visits over a 6 month period between children with asthma in an intervention study group (n = 12) and children with asthma in a control study group (n = 7). The intervention study group received intense asthma education, three home visits, 2 week follow-up telephone calls, and environmental intervention products for reducing asthma triggers in the home. The control group received education at baseline and 2 week calls, but no intervention products. RESULTS At the end of the study period, significant improvements were observed in the intervention group compared with the control group. Overall, the intervention group experienced a 58% (46 ± SD 26.9) reduction in self-reported asthma symptoms; 76% (34 ± SD 29.7) decrease in rescue medicine; 12% (145 ± SD 11.3) increase in controller medicine; 37% decrease in mean exhaled nitric oxide levels and 33% fewer ED asthma-related visits. CONCLUSION As demonstrated, a combination of efforts appeared effective for improving asthma respiratory symptoms among children in the intervention group. ECAPP is a low cost pilot project that could readily be adapted and expanded into other communities throughout eastern North Carolina. Future efforts could include enhanced partnerships between environmental health professionals at local health departments and pediatric asthma programs at hospitals to carry out ECAPP.
    Full-text · Article · Jun 2014 · Environmental Health Insights
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    • "n 2002 and 2003 prior to an integrated pest management intervention from 42 homes of pediatric asthmatics living in public housing in Boston , MA , as part of the Healthy Public Housing Initiative , a large - scale collaboration focused on pediatric asthma and indoor allergens in public housing ( Clougherty et al . , 2006 ; Julien et al . , 2008 ; Levy et al . , 2006 ; Peters et al . , 2007 ) . Homes where the concentrations were measured were urban apartments that had a square footage of approximately 65 – 84 m 2 ( Zota et al . , 2005 ) , and with bedrooms and living areas in relatively close proximity to kitchens and bathrooms . Details about the sampling protocol are available in Julien et al . ("
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    ABSTRACT: Pesticide exposure in urban low-income residential environments may be elevated as a result of persistent application due to severe pest infestation. Children living in this environment may be a sensitive subpopulation for these non-dietary exposures, due to their physiological and behavioral differences. In this study, we provide an exposure modeling framework to simulate exposures for children in this environment and assess dominant exposure routes and sources of exposure variability, in order to characterize factors that influence risk. We use a dataset of pesticide measurements collected in 42 low-income dwellings, including vacuum dust and floor wipe samples from kitchens and living rooms. We fit distributions to the concentration measurements for the organophosphates measured, chlorpyrifos and diazinon, and the most prevalent pyrethroids (permethrin, cypermethrin, and cyfluthrin), and simulated 1000 homes from the distributions. Concentration measurements were then connected with activity pattern data, short-term dermal and ingestion exposures and absorbed doses were simulated for children ages 1-5 years. For both pesticide groups, exposure values ranged widely, with concentration values contributing most significantly to exposure variability, although approximately 20-fold variability was attributable to exposure factors alone. In addition, upper percentile exposed children usually had both higher concentrations as well as greater influences from exposure and dose factors. Differences were also seen across pesticide groups in dominant exposure pathways. Our analyses indicate a profile of factors that describe individuals likely to receive high doses of one or multiple pesticides and could allow for more targeted intervention strategies. More generally, this work provides a standard framework to evaluate and describe exposures to prevalent residential pesticides via multiple pathways.
    Full-text · Article · May 2013 · Environmental Research
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    • "Because of the multi-factorial nature of asthma exacerbations, it can be challenging to design optimal intervention strategies. Studies have demonstrated public health benefits of residential interventions such as using community health workers to provide asthma education [11,12], conducting integrated pest management [13,14], or multi-factorial indoor interventions [15]. It is difficult to make generalized conclusions about intervention efficacy, because of significant differences in context and risk factors for various populations, as well as the possibility that intensive interventions using community health workers have significant social support components that provide benefits beyond improvements in the physical environment [16]. "
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    ABSTRACT: Background In the United States, asthma is the most common chronic disease of childhood across all socioeconomic classes and is the most frequent cause of hospitalization among children. Asthma exacerbations have been associated with exposure to residential indoor environmental stressors such as allergens and air pollutants as well as numerous additional factors. Simulation modeling is a valuable tool that can be used to evaluate interventions for complex multifactorial diseases such as asthma but in spite of its flexibility and applicability, modeling applications in either environmental exposures or asthma have been limited to date. Methods We designed a discrete event simulation model to study the effect of environmental factors on asthma exacerbations in school-age children living in low-income multi-family housing. Model outcomes include asthma symptoms, medication use, hospitalizations, and emergency room visits. Environmental factors were linked to percent predicted forced expiratory volume in 1 second (FEV1%), which in turn was linked to risk equations for each outcome. Exposures affecting FEV1% included indoor and outdoor sources of NO2 and PM2.5, cockroach allergen, and dampness as a proxy for mold. Results Model design parameters and equations are described in detail. We evaluated the model by simulating 50,000 children over 10 years and showed that pollutant concentrations and health outcome rates are comparable to values reported in the literature. In an application example, we simulated what would happen if the kitchen and bathroom exhaust fans were improved for the entire cohort, and showed reductions in pollutant concentrations and healthcare utilization rates. Conclusions We describe the design and evaluation of a discrete event simulation model of pediatric asthma for children living in low-income multi-family housing. Our model simulates the effect of environmental factors (combustion pollutants and allergens), medication compliance, seasonality, and medical history on asthma outcomes (symptom-days, medication use, hospitalizations, and emergency room visits). The model can be used to evaluate building interventions and green building construction practices on pollutant concentrations, energy savings, and asthma healthcare utilization costs, and demonstrates the value of a simulation approach for studying complex diseases such as asthma.
    Full-text · Article · Sep 2012 · Environmental Health
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