Home Environmental Interventions Research Articles

NIAID, NIEHS, NHLBI, and MCAN Workshop Report: The indoor environment and childhood asthma—implications for home environmental intervention in asthma prevention and management

Environmental exposures have been recognized as critical in the initiation and exacerbation of asthma, one of the most common chronic childhood diseases. The National Institute of Allergy and Infectious Diseases; National Institute of Environmental Health Sciences; National Heart, Lung, and Blood Institute; and Merck Childhood Asthma Network sponsored a joint workshop to discuss the current state of science with respect to the indoor environment and its effects on the development and morbidity of childhood asthma. The workshop included US and international experts with backgrounds in allergy/allergens, immunology, asthma, environmental health, environmental exposures and pollutants, epidemiology, public health, and bioinformatics. Workshop participants provided new insights into the biologic properties of indoor exposures, indoor exposure assessment, and exposure reduction techniques. This informed a primary focus of the workshop: to critically review trials and research relevant to the prevention or control of asthma through environmental intervention. The participants identified important limitations and gaps in scientific methodologies and knowledge and proposed and prioritized areas for future research. The group reviewed socioeconomic and structural challenges to changing environmental exposure and offered recommendations for creative study design to overcome these challenges in trials to improve asthma management. The recommendations of this workshop can serve as guidance for future research in the study of the indoor environment and on environmental interventions as they pertain to the prevention and management of asthma and airway allergies.

Pediatric Emergency Department Return: A Literature Review of Risk Factors and Interventions.

Children discharged from emergency departments (EDs) are often at risk for ED return. The objective was to identify risk factors and interventions to mitigate or prevent ED return among this patient population. Structured literature review of PubMed and clinicaltrials.gov was conducted to identify relevant studies. Inclusion criteria were studies evaluating ED returns by identifying risk factors and interventions in the pediatric population. Emergency department return was defined as returning to the ED within 1 year after initial visit. Abstract and full text articles were reviewed, and data were abstracted by 2 independent authors. A total of 963 articles were screened and yielded 42 potential relevant articles involving pediatric population. After full text review, a total of 12 articles were included in the final analysis (6 on risk factors and 6 on interventions). Risk factors for pediatric ED return included behavioral/psychiatric problems, younger age, acuity of illness, medical history of asthma, and social factors. Interventions included computer-generated instructions, postdischarge telephone coaching, ED-made appointments, case management, and home environment intervention. Emergency department-made appointments and postdischarge telephone coaching plus monetary incentive improved outpatient follow-up rate but not ED return. Home environment assessment coupled with case management reduced ED returns specifically among asthma patients. Several patient and visit characteristics can help predict children at risk for ED return. Although some interventions are successful at improving postdischarge follow-up, most did not reduce ED returns.

Physical changes in the home environment to reduce television viewing and sugar-sweetened beverage consumption among 5- to 12-year-old children: a randomized pilot study.

This study evaluated the feasibility of a home-based intervention to reduce sugar-sweetened beverage intake and television viewing among children. Lower income parents of overweight children aged 5-12 years (n = 40) were randomized to a home environment intervention to reduce television viewing with locking devices and displace availability of sugar-sweetened beverages with home delivery of non-caloric beverages (n = 25), or to a no-intervention control group (n = 15) for 6 months. Data were collected at baseline and 6 months. After 6 months, television viewing hours per day was significantly lower in the intervention group compared with the control group (1.7 [SE = .02] vs. 2.6 [SE = .25] hours/day, respectively, P < .01). Sugar-sweetened beverage intake was marginally significantly lower among intervention group compared to control group children (0.21 [SE = .09] vs. 0.45 [SE = .10], respectively, P < .09). Body mass index (BMI) z-score was not significantly lower among intervention compared to control children. Among a lower income sample of children, a home-based intervention reduced television viewing, but not sugar-sweetened beverage intake or BMI z-score.

PRS46 - Improved Health Care outcomes and Cost Savings for Asthma Through Targeted Home Interventions

PRS46 ImPRoved HealtH CaRe outComeS and CoSt SavIngS foR aStHma tHRougH taRgeted Home InteRventIonS Norlien K.G.1, Carlson A.M.2, York P.V.1 1Minnesota Department of Health, St. Paul, MN, USA, 2Data Intelligence Consultants, LLC, Eden Prairie, MN, USA Objectives: Studies have demonstrated the importance of the environment both on the development of asthma and on exacerbation of asthma symptoms in those who have been diagnosed with the disease. The goal of this project was to provide in-home asthma services that covered both self-management education and home environmental interventions for children diagnosed with asthma living in Section 8 Multi-family Housing. MethOds: This HUD-funded project consisted of 3-4 home visits by a public health nurse over a one year period—an in-home baseline visit; a visit to deliver allergen-reducing products if needed; and 6 and 12-month follow-ups by phone or in-home visit. Data was collected on asthma status (health-related quality of life and asthma control), health service utilization (hospitalizations, ED and office visits) and school and/or work absences due to asthma. Data analysis was completed using SAS v9.3. Results: 219 children from 161 low income families were enrolled from five participating local public health agencies in a large metropolitan area. The low cost interventions provided, resulted in significant increases in the proportion of enrollees experiencing minimal to no daytime and nighttime symptom burden and functional limitations at the 12-month follow-up (p< 0.05). Overall health care service use declined. There was a significant reduction in school days missed (p< 0.05), the equivalent of 5 school days per child per year. The average cost per family of interventions, was $424 (e.g. mattress and pillow encasements, HEPA vacuum cleaners, air purifiers). Program administrative costs per family were $585 (e.g. enrollment costs, travel time, visit time and documentation). cOnclusiOns: This study provided additional support for the usefulness and success of providing home interventions for low income children who have been diagnosed with asthma. Low cost, targeted interventions led to improvements in HRQOL, decreased health service utilization, increased school attendance and a positive return on investment.

173 Clues for the Neurodevelopmental Prognosis of the High Risk Preterm and Term Newborns

Premature survivors are at increased risk for impaired neurodevelopmental outcome compared to full terms. These sequelae include cognitive abnormalities, mild fine or gross motor delay, cerebral palsy, vision and hearing...

Children’s Hospital Boston Community Asthma Initiative: Partnerships and Outcomes Advance Policy Change

Rates of poorly controlled asthma among low-income children, particularly racial and ethnic minorities, remain disproportionately high. Comprehensive asthma programs, including education, case management and home environmental interventions have reduced disparities. Few sustainable payment models exist. The Children's Hospital Boston's Community Asthma Initiative (CAI) demonstrated dramatic reductions in hospitalizations and emergency department (ED) visits among African American and Latino patients with a return on investment (ROI) of 1.46. A strong coalition focused on sustainability plus CAI outcomes contributed to the state legislature's approving a bundled payment pilot for high-risk pediatric asthma patients on Medicaid/MassHealth. Cost-effective, comprehensive asthma programs and policy makers' interest in new payment models created an opportunity for a new payment approach for pediatric asthma care. A community coalition that successfully addresses asthma health disparities with a strong business case and program outcomes can be leveraged to persuade policy makers of the value of innovative financing strategies for asthma care.

The Economic Value of Home Asthma Interventions

r n d p c t i s P v e Asthma is a common and costly chronic illness affecting people of every economic level, demographic category, and age group. People with asthma can be disabled by their illness, especially during acute episodes, and unable to performbasic life tasks such as attend school or work. Properlymanaged, however, ndividuals with asthma can lead a normal life, including articipating in sports and other activities, and high-cost vents, such as visits to the emergency department or npatient hospital care can be avoided. The review preented in this supplement to the American Journal of reventive Medicine by Nurmagambetov et al. shows that comprehensive home environmental interventions have the potential to be cost-effective interventions for children with asthma. This is particularly true if the programs reduce the use of healthcare resources devoted to treating acute asthma exacerbations brought on by triggers in the home environments. The National Asthma Education and Prevention Program suggests that optimal management of asthma depends on three crucial elements:

Nurse case management and housing interventions reduce allergen exposures: the Milwaukee randomized controlled trial.

We examined the impact of a combination of home environmental interventions and nurse case management services on total settled dust loadings and on allergen concentrations in the homes of asthmatic children. METHODS Using a randomized longitudinal controlled trial study design, we randomly assigned homes of asthmatic children in Milwaukee to either a control (n = 64) or an intervention (n = 57) group. Control group homes received a visual assessment, education, bed/pillow dust mite encasings, and treatment of lead-based paint hazards. The intervention group received these same services plus nurse case management that included tailored, individual asthma action plans, provision of minor home repairs, home cleaning using special vacuuming and wet washing, and integrated pest management. Dust vacuum samples were collected from measured surface areas of floors in the TV room, kitchen, and child's bedroom at baseline and at three-, six-, and 12-month follow-up visits. Dust loading (mass per surface area) is a means of measuring total dust and the total amount of allergen present. For the intervention group, geometric mean dust loadings declined significantly from baseline (39 milligrams per square foot [mg/ft2]) to postintervention (11 mg/ft2) (p < 0.001). Baseline dust loading, treatment group, visit, and season were significant predictors of follow-up dust loadings. Mean post-intervention dust loadings were 72% higher in the control group. The total amount of allergen in settled house dust declined significantly following the intervention because total dust loading declined; the concentration of allergens in settled dust did not change significantly. The combination of nurse case management and home environmental interventions promotes collaboration between health and housing professionals and is effective in reducing exposures to allergens in settled dust.

The effect of low-cost modification of the home environment on the development of respiratory symptoms in the first year of life

Previous studies have suggested that environmental exposures may be related to the development of respiratory symptoms in early life. Intervention studies, however, have not produced consistent findings. The Peer Education in Pregnancy Study examined the effect of home environment intervention with pregnant women at risk for having children with asthma on the development of respiratory symptoms in their infants. A total of 383 pregnant women whose unborn child had a first-degree relative with an allergic history were randomized to 1 of 2 intervention groups, both of whom received general health education, smoking cessation advice, and encouragement to breastfeed. In addition, the intensive education group received 3 home visits focused on home environment modification. Home assessment was performed at baseline and after 1 year of follow-up. Respiratory symptoms were identified during the first year of life. Families in both intervention groups showed significant changes in several environmental factors, with significant differences between the 2 groups in insects other than cockroaches, use of mattress covers, and washing in hot water. Children in the intensive education group had slightly lower incidence rates of respiratory symptoms, but few differences were statistically significant. The results of this study do not provide strong support for a primary intervention focused on general modification of the home environment during pregnancy for high-risk children. It does not address the effects of more aggressive approaches or of interventions targeting individual environmental factors.

Home Environmental Intervention in Inner-City Asthma: A Randomized Controlled Clinical Trial

Eggleston PA, Butz A, Rand C, et al. Ann Allergy Asthma Immunol. 2005;95:518–524 PURPOSE OF THE STUDY. To conduct a randomized, controlled clinical trial to test the efficacy of home-based methods to reduce environmental pollutants and allergen exposure in the homes of asthmatic children living in an inner city. STUDY POPULATION. One hundred asthmatic children, ranging in age from 6 to 12 years, with physician-diagnosed asthma, current asthma symptoms, and no other chronic lung disease. METHODS. The families were randomly assigned to a treatment group that received intervention immediately (home-based education, cockroach and rodent extermination, mattress and pillow encasings, and a high-efficiency particulate air cleaner) or to a control group that received intervention at the end of the 1-year trial. In the treatment group, 84% received cockroach extermination, 70% received mouse extermination, and 75% used the air cleaner. Outcomes were evaluated against baseline by home evaluation at 6 and 12 months, clinical evaluation at 12 months, and multiple telephone interviews. RESULTS. Home particulate concentrations were lower at both 6 and 12 months in the treatment group. Home levels of particulate matter ≤10 μm declined by up to 39% in the treatment group as compared with an increase in the control group (P &amp;lt; .001), and cockroach-allergen levels decreased by 51% in the treatment group (P = .04). The proportion of symptomatic children increased in the control group and decreased in the treatment group, with significant differences seen at 6 months and later. In addition, children in the treatment group were significantly less likely to report daytime symptoms during the first 9 months compared with those in the control group. However, the mean difference in daytime symptoms over 12 months was only marginally significant (P = .07). Other measures of participant morbidity, such as nighttime symptoms, emergency department use, and spirometry findings, were not significantly changed during the study period. CONCLUSIONS. A tailored program of environmental and behavioral interventions to reduce indoor particulate matter and other relevant allergen levels in low-income, inner-city homes had a modest effect on asthma morbidity. REVIEWER COMMENTS. It is interesting to note that few of the 69% of the households with smokers in them changed smoking habits. Most likely, the environmental-control measures outlined in this article, implemented as part of a more comprehensive treatment plan including smoking cessation, could contribute more significantly to symptom reduction.

Home Environmental Intervention in Inner-City Asthma: A Randomized Controlled Clinical Trial

Home Environmental Intervention in Inner-City Asthma: A Randomized Controlled Clinical Trial

Using Telerehabilitation to Support Elders With Chronic Illness in Their Homes

As the number of persons with disabilities increases because of factors such as aging combined with chronic illnesses, the challenge of providing rehabilitation also increases. Unfortunately, financial considerations have shortened length of stay in acute and subacute settings and reduced rehabilitation services. With earlier discharges, there is an increased need to deliver services to patients in their homes in an efficient and cost-effective manner. Telerehabilitation is an emerging practice that uses communications technology for the remote delivery of rehabilitative care. The Low ADL Monitoring Program is a telerehabilitation program designed to deliver rehabilitation services through the provision of home environmental interventions, together with communications technology and care coordination.

Home environmental intervention in inner-city asthma: a randomized controlled clinical trial

Airborne pollutants and indoor allergens increase asthma morbidity in inner-city children; therefore, reducing exposure, if feasible, should improve asthma morbidity. To conduct a randomized controlled trial of methods to reduce environmental pollutant and allergen exposure in the homes of asthmatic children living in the inner city. After the completion of questionnaires, spirometry and allergen skin tests, home inspection, and measurement of home air pollutant and allergen levels, 100 asthmatic children aged 6 to 12 years were randomized to the treatment group (home-based education, cockroach and rodent extermination, mattress and pillow encasings, and high-efficiency particulate air cleaner) or to the control group (treated at the end of the 1-year trial). Outcomes were evaluated by home evaluations at 6 and 12 months, clinic evaluation at 12 months, and multiple telephone interviews. In the treatment group, 84% received cockroach extermination and 75% used the air cleaner. Levels of particulate matter 10 microm or smaller declined by up to 39% in the treatment group but increased in the control group (P < .001). Cockroach allergen levels decreased by 51% in the treatment group. Daytime symptoms increased in the control group and decreased in the treatment group (P = .04). Other measures of morbidity, such as spirometry findings, nighttime symptoms, and emergency department use, were not significantly changed. A tailored, multifaceted environmental treatment reduced airborne particulate matter and indoor allergen levels in inner-city homes, which, in turn, had a modest effect on morbidity.

Applying Population Health Models

In this issue of the Journal, guest editors Daniel Friedman and Barbara Starfield have gathered together and added their voices to an outstanding collection of articles on models for population health. Together, they ask: Do theory and models matter in the conduct of public health research and practice? As researchers involved in community-based public health interventions and programs in Harlem, New York City, our answer is a resounding “yes!” The salience of the population health perspectives presented in this issue is made manifest in relation to 2 of our current projects—namely, evaluation of the Harlem Children’s Zone Asthma Initiative and analysis of the Harlem Household Survey. Both projects were implicitly shaped by what we would now term a population health perspective, in that the health needs of entire communities are embraced and individual, neighborhood, and societal factors are considered important for health and well-being. The theory and models presented in this issue—by explicitly delineating components of population health frameworks and models—can aid such efforts by helping us to conceptualize the pathways through which various factors influence health, thereby suggesting points of intervention and questions to ask when obtaining or analyzing data. The Harlem Children’s Zone Asthma Initiative added a public health component to the longstanding work on school truancy and community-building of the Harlem Children’s Zone, Inc, and the community-based health service delivery efforts of the Department of Pediatrics of Harlem Hospital Center. Building upon a population-based survey of adults in Central Harlem (the Harlem Household Survey), our evaluation perspective was enriched by a history of community-based public health research at the Harlem Health Promotion Center. By embracing a holistic population health perspective, we were able to pull together work with children and with adults, in hospitals and in schools, in our current efforts. This meant shoring up a public hospital center (pediatric ward, emergency department, and clinic) and public school infrastructure with private funding and tailored programs to ensure that the needs of every child in the Harlem Children’s Zone Project are met. One of the things we are learning, according to Dr. Stephen Nicholas, Director of Pediatrics at Harlem Hospital Center, is that coming into people’s homes to deliver interventions helps to remove communication barriers between health care providers and families. In doing so, we hope to improve the health and well-being of all household members—children and adults alike—through home visits for education in medication usage, family-centered primary health care services, and home environmental interventions to remove asthma triggers. The population health perspective does more than encourage these kinds of linkages—it facilitates them. Further, it underscores the need for researchers to use multidisciplinary approaches, to integrate qualitative and quantitative methods, and to recognize the importance of lay knowledge and participatory research (Young TK. Population Health: Concepts and Methods. New York: Oxford University Press Inc; 1998). Steeped in the conduct of community-based research, we can thoughtfully assess which population health models are relevant to our experiences and consistent with our values. Applying population health models—with their emphasis on social processes and conditions—affords an opportunity to test whether interventions that address social inequalities will reduce gaping health disparities across and between populations.

Home and allergic characteristics of children with asthma in seven U.S. urban communities and design of an environmental intervention: the Inner-City Asthma Study.

Most published environmental remediation interventions have been directed at single allergens and have employed demanding strategies; few have been performed in the homes of inner-city children disproportionately burdened by asthma. Our objective was a) to describe the allergen sensitivities, environmental tobacco smoke (ETS) exposure, and home environmental characteristics of a national sample of inner-city children with moderate to severe asthma and b) to develop and implement a multifaceted, home-based comprehensive intervention to reduce home allergens and ETS, tailored to the specific sensitization and exposure profiles of those children. Allergen skin testing and a home evaluation were performed to determine the presence of ETS and factors known to be associated with increased indoor allergen levels. Based on published remediation techniques, a home environmental intervention, organized into modules, each addressing one of five specific allergen groups or ETS, was designed. Of 994 allergic children from seven U.S. urban communities, 937 successfully completed baseline interviews and home allergen surveys and were enrolled. More than 50% of children had positive skin tests to three or more allergen groups. Cockroaches were reported in 58% of homes, wall-to-wall carpeting in the child's bedroom in 55%, a smoker in 48%, mice or rats in 40%, and furry pets in 28%. More than 60% of enrolled families received four or more modules, and between 94% and 98% of all modules were completed. We conclude that most inner-city children with moderate to severe asthma are sensitized to multiple indoor allergens and that environmental factors known to be associated with asthma severity are commonly present in their homes. The intervention developed for the Inner-City Asthma Study employs accepted methods to address an array of allergens and ETS exposure while ensuring that the intervention is tailored to the specific sensitization profiles and home characteristics of these children.

Using TeleRehabilitation to provide home environmental interventions

Using TeleRehabilitation to provide home environmental interventions

Predicting Participation and Adherence to a Home Environmental Intervention among Family Caregivers of Persons with Dementia

We examined predictors of participation and adherence to a home environmental intervention with 100 dementia family caregivers. Participation was measured as the number of home visits, adherence as the number of problems addressed, and strategies used. Being older and female predicted participation. Adherence was predicted by older age, lower depression, and having a less dependent person to care for We speculate that depression should be viewed as a moderator of treatment, not an outcome.