Controlling Asthma in American Cities: major themes, persistent challenges, and next steps.

Abstract

The papers in this special supplement provide a sampling of the accomplishments, challenges, and contributions of the Controlling Asthma in American Cities Project (CAACP)—a large, complex project implemented through community-based coalitions at seven inner-city sites. The core purpose of the CAACP was to improve asthma control for children suffering from a high disease burden. The epidemiologic trends and increasing public health burden that drove the initial funding of this project appear in the introductory paper; the conceptual and theoretic framework behind the design of the project are presented in the second. Subsequent papers detail individual site interventions or specific interventions as implemented across sites. This supplement will be of interest to a variety of audiences including community asthma coalitions, community-based organizations that serve children, healthcare provider groups and organizations, insurers (including Medicaid programs), state asthma programs, and academics. This editorial analyzes the major themes reflected in the papers, summarizes the persistent challenges, and suggests next steps for improving asthma control in urban communities. The CAACP is an important translational initiative and a step in the progression from intervention-focused efficacy research through project-based implementation to scaled-up field implementation by coalitions, healthcare systems, and state asthma programs. As an example of this progression, in-home interventions to provide self-management training and reduce asthma triggers, a component of all the CAACP projects, was first proven effective through a research design in the NIH-funded National Cooperative Inner City Asthma Study1, then shown to work in additional settings through the Allies Against Asthma community coalitions2 and CAACP communities3, and has now been recommended by the Task Force on Community Preventive Services for use in other communities. A similar model of coalition-implemented multi-faceted asthma projects, including in-home interventions, continues currently with the Merck Childhood Asthma Network4. Such a translational progression shows that interventions can work with various sources of support and that the interventions can be effectively modified for different contexts. CAACP provided valuable information about the factors which led community partners to sustain interventions without further funding. As with previous projects and studies, the target population of the CAACP project was children with asthma. The intent was to implement evidence-based interventions appropriate to local cultures and needs and at multiple levels (individual, interpersonal, community, institutional, and policy)5. There was room for some experimentation with innovative interventions and approaches, and an emphasis on monitoring effectiveness throughout the 5-year implementation phase, as well as measuring impact at the population level.